SNIDigital Innovations in Learning

SNI, Surgical Neurology International, an Internet Journal, with Nancy Epstein as etc. in Chief, an SNI Digital, an editorly curated, neurosurgery and

medical information, multimedia platform with operative videos, expert interviews, podcasts, global interactive discussion of information for the next generation of clinicians with James Osmond as

its editor-in-chief.

In cooperation with the Sub-Saharan African neurosurgeons are pleased to present another in the series of Sub-Saharan African International Neurosurgery Grand Rounds held on the first Sunday of each

month.

In addition to the Latin American Neurosurgery International Grand Rounds sponsored by SNI and SNI Digital on the last Sunday of each month.

Are both pleased to present? the 22nd subsidy or an international neurosurgery grand rounds with a major subject of global solutions to clinical challenges in neurosurgery. Strada Bernard is the

head of the SNI Digital Grand Rounds programming, and this program is co-moderated by James Houseman.

Dr. Bernard is formally on the Duke University faculty in neurosurgery. He's former head of neurosurgery at the University of North Carolina.

His interests are neurosurgery, spine, brain, and pain. He's on the board of directors of SNI Digital. He's head of SNI Digital Grand Rounds programs in Sub-Saharan Africa and Latin America.

And the first talk in this program is going to be on metastatic spinal tumors by Andrew Veevas in the United States.

Andrew is the Director of Adult and Pediatric Spinal Deformity in Neurosurgery and UCLA. He's the Co-Director of Complex and Minimally Invasive Spine Fellowship Program, Associate Program Director

of Neurosurgery Residency, System Professor in the Department of Neurosurgery, Pediatric Surgery, Radiation Oncology, All at the UCLA Health, David Geffen School of Medicine.

Second speaker is Ben Matuso, and Kenya will talk about a post-operative spinal epidural hematoma.

Ben is a consultant neurosurgery at the Defense Forces Hospital just outside of Kenya

You can see in this map of Kenya where the red circle shows Nairobi. A few words about Kenya. It's a country in East Africa. You can see that on the inset map

shown at the bottom left. And it's known for its scenic landscapes with vast wildlife reserves. It's located on the Indian coast, which historically becomes a very important port city, which goods

from the Arab and Asian traders have entered over for many centuries. Along that coast, which holds some of the finest beaches in Africa are predominantly Muslim, Swahali cities, such as Mombasa,

UC on the bottom, a historic center that's contributed much to the musical and culinary heritage of the country. Inland, its very populous highlands, are famed for both of their tea plantations,

which is a remnant of these British occupation during the colonial area, and a variety different animal species including. Lions, elephants, cheetahs, rain, offsergies, and hippopotamuses.

Western Kenya, as you can see, is marked by lakes, rivers, and wild deserties and semi-desiraries are found more in the north and central south. The country's diverse wildlife and panoramic

geography draw large numbers of visitors and tourism, which is an important contributor to its economy.

These are some references of Dr. Vivas. Take a screenshot of these and they're listed with the topic on which their subject matter is. Take a screenshot of these for your records. Let me introduce

Dr. Vivas.

He's at the UCLA. He's the Director of Adult and Pediatric Deformity He's based at UCLA and, I guess, specifically at the UCLA Santa Monica Comprehensive Spine Center. I heard you say you also

associate program director of the UCLA Nursery Training Programs. So we welcome you and we're looking forward to hearing your presentation. Alrighty. Well, thanks again for having me on really a

great pleasure. I'll go ahead and share my slides here.

Is everybody able to see my slide deck? Yes. Oh, fantastic. Let me expand this so I can see everybody. Andrew, would you mind if you're giving you talk, we ask questions? Please do. Let's see,

what is this doing here? Continue to share. Is everybody still seeing the slides not present or mode? That's correct. Yes Okay, lovely. Yeah, I'm going to try to get through this. Dr. Osman,

feel free to interrupt. Anybody else feel free to interrupt? Full disclosure, this lecture was full grand rounds over an hour and a half lecture. I'm going to truncate it and squeeze it into this

30-minute block, but I'm going to gloss over some things. If anybody wants this slide deck to educate their residents, Fellows or even just to have as a resource. please feel free to reach out to

me. I'm happy to share these slides in the interest of advancing our field together. So with that, these are my disclosures and I'm relevant to today. So, Andrew. So learning objectives,

essentially we're gonna go through spine tumors that any neurosurgeon will encounter throughout their career. I broke this talk up into four different subsections. The first being a brief overview

of primary CNS tumors The second, probably salient to a lot of our colleagues, metastatic spinal disease. Third, primary bony spinal tumors. I do a lot of that kind of work just by virtue of my

background and spinal deformity, a lot of unblock spondolectomies and things like that. And then a case-based discussion to really drive home some of

the points of management of spinal tumors. So broadly speaking, when we speak about spinal tumors, We talk about things that are - originating from outside of the Dura, things that originate from

inside the Dura, but outside the spinal cord proper, and then things that originate from within the spinal cord. So these are the three big buckets of tumors. Most common metastatic tumor that we

all deal with, most common extra-dural tumor that we all deal with are our metastatic tumors. We can also get some of the primary bony tumors, things like cordomas, counter-circumas, and giant

cell tumors Those typically do not invade the dura. Rarely, you can't see metastatic tumors that originate in the epidural space and go through the dura. I can think of once or twice, I've seen

that in my career thus far. Intradural extra-medullary tumors, the most common ones,

meningioma, schwannoma, neurofibroma. Mixed with papillary appendomomas are broadly speaking, more of an intramedullary tumor, but the ones that originate. from below the conus, you could

categorize as being extramagilary. And then of course, intermeagilary tumors at the endomoma, astrostoma, hemangioblastoma. These are the three most common. More rarely you can see things like

lymphoma or metastatic disease. So spinal meningiomas are the most common tumors, most common intra-dural extramagilary tumors that we'll deal with. A slight female predilection that is found most

often in the six and seventh decade of life. These things tend to be in the thoracic spine, probably just because there's more thoracic dura and thoracic arachnoid capsules than there are in the

cervical and lumbar spine. Most of these are benign tumors. They can be calcific, they're dural-based and well-subscribed. And these, as everyone here knows, cause damage by virtue of mass

effect on the surrounding neural elements. Gross total resection is the standard of care with things like radiotherapy reserved for recurrent disease or grade two disease. And here the image on the

right panel showing their classic meningioma ventral here at the cervical thoracic junction. Nerve-seat tumors are the second and third most common intradoraloxramesular tumors, which typically

originate from the lining of the nerves. From the Schwann cells, so Schwannomas, neurofibromas, likewise, like the

meningioma counterparts cause issue most often by mass effect on the surrounding neural elements. Spinal appendamomas are the most common intramedular tumor in adults. They originate from the

appendymal lining.

And typically, Ahhh. Typically, we will see a homogenous enhancing lesion within the

spinal cord proper as well, as well as a typical cap sign, which is a sign of hemociderin deposition. Surgery is the primary management of these kinds of tumors, gross total resection being the

goal. In instances of gross total resection, particularly if you can keep the capsule of the tumor

intact, there's excellent long-term disease-free survival. For subtotal resections, unfortunately, there's pretty much a 100 rate of recurrence, and subtotal resections are typically treated with

radiotherapy

Final astrocytomas are a

more rare entity, but still the second most common intermeasure tumor. They can be low grade tumors. They can be quite indolent for long periods of time. And they can also be higher grade glial

tumors, glial blastome of the spinal cord.

These things can just be non-enhancing lesions which expand the cord or they can be ring enhancing. They can have areas of

necrosis, central necrosis which can result in ring enhancement And, you know, the management of these intramagillary tumors is quite controversial. I was giving a story to some of my residents

that I have a child that I saw in consultation with an intramagillary tumor that was diagnosed actually incidentally, the child had a history of craniosinostosis and underwent surgical correction for

that and was getting an MRI, a surveillance MRI where they happened to pick up an expansion of the cervical spinal cord that looked concerning for an intramagillary astrocytoma. Now, this child was

two years old and really was asymptomatic. And so we elected to observe him. It's now been about six years that we've been observing the child. And there was an initial period of expansion of the

tumor and then subsequent regression of the tumor So we know that it's still there, but it's behaving in a very intelligent fashion. The child is now eight or nine years old. And so we continue to

monitor it. It has no enhancement. These are the images actually. And so we've just been monitoring it.

I cared for a woman who was in her mid-40s, who was diagnosed with an astrocytoma as a child and had

an attempted resection, is a subtotal or a section, maximal safer section. Um, with no subsequent growth of the tumor across, you know, 30 years. So, you know, the behavior of these is, is,

uh, variable and, uh, the management of them, you know, right now I'd say is, is, uh, done on a case-by-case basis because we really don't understand the natural history of this disease.

Final Hemanjo blastomas, third most common tumor. We commonly see them in patients with fun-hippled Lindau syndrome, uh, who can get, uh, Hemanjo blastomas, not just of the spinal cord, but

also of the cerebellum. Uh, they're typically small, uh, um, very avidly enhancing lesions. They're quite bloody, uh, quite vascular and, uh, typically associated with some sort of cyst, uh,

or syrinks, uh, the cyst and syrinks don't necessarily need to be resected at the time of surgery, but the entirety of the enhancing nodule does need to be resected, uh, lest the, uh, cyst and,

um, syrinks recurve.

Moving on to. Andrew, before you start, go to the next section.

We can ask

Dr.

Jima who's in northern Nigeria. Do you see, you have a large department there, do you see spinal cord tumors often, and what's your experience? Yes, I do. Not as often. Um, recently, I

operated a 17-year-old. We see how this is a logical dilemma though. A 17-year-old that I first operated about November last year, and it's an extra direct tumor. Um, it's a logical way to

control an excite tumor, but it rapidly report

and to an extent that the second time he came he was still he was he came very paraplegic specific paraplegia and we re-operated this time around grossly looked as if it was a

meninguma with the effectiveness of the bone and then somebody second time this second time him as a

OSU coma as a lot of the doubts I took the two block to the to another center for an opinion I was hoping to get it on Friday but hoping to get it tomorrow this Monday we've had many geomass like the

presenter rightly said more in women

in the thoracic or paparazzic region We've had a chuanoma, part of its synchronic neurofibromatosis, like one. We've had a pengainoma, we've had one or two astrocytoma I think basically does the

experience I've had in the final two months.

In this area, we're not going to get it. Thank you, Sam. Are you there, Sam? Yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes,

yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes,

yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes, yes,

yes, Okay, and Ben Matuso,

Ben? I'm sorry, Sam, I interrupted you, I'm sorry. It was me, Jim. No, no, go ahead. What I was going to say is I had asked Andrew to focus on metastatic spinal tumors because my perception

is that the neurosurgeons in Sub-Saharan Africa see more of that than the primary tumors, but I may be mistaken. So I'd like the surgeons there from Sub-Saharan Africa to weigh in on that concept.

What proportion is spinal tumors and metastatic versus the primary tumor?

Sam, Sam, do you wanna answer that? Do you have more? Yes, we see. We see a lot of metastatic tumors, but it's deflockful, it's like most things that we see. Sometimes you see serious of them.

Other times we're seeing a mixture of non - metastatic I think too much, but I suspect. There is more to it because many of the cases may not even come to us. They are managed by colleagues,

urologists, and orthopedic surgeons, because many of these bank cases go to the specialists. And what they see is metastatic, they say, well, what I did, you can ask, we are managed with, you

know, by, without, for example, oncologist. So I suspect there's more to it that we don't see But we see a lot of variety in this point, you must.

Okay, so we got an idea that this is, and not uncommon there, that they see this, these tumors a lot, Stratus. So Andrew there gives you a little background of two major centers in Nigeria and

what they're thinking about. Yeah, absolutely. So,

pardon me. So we're gonna go into good depth on metastatic spinal tumors per our discussion as strata. So I just wanna talk a little bit about the management of spinal metastatic spinal tumors

before we do some of the epidemiology. So 70 of cancer patients end up with spinal meds at autopsy. This tells you that there's a high predilection of metastasis to the spine for all different types

of primary disease. About 10 of them will develop symptomatic epidural spinal cord compression. And the spine is the number one most common site of osteosmetastatic disease. So just like our other

panelists and guests are saying, this is a very prevalent problem. Lung cancer is the most common primary source

comprising about 30 to 40 percent of of metastatic spine tumors. These tumors tend to be osteolytic, and so unfortunately can come issues with pathologic fractures. And these lung tumors, although

there is some obviously a distinction between small cell and non-small cell cancers, for the non-small cell variants, they tend to be radio resistant. Breast cancer is the next common, next most

common comprising about 20 to 30 of metastatic disease that can be both plastic or lytic or have a mixed characteristic and they tend to be relatively radio sensitive. There's probably a difference

in the plastic disease depending on what the hormonal markers are, whether it's estrogen or progesterone sensitive.

Prostate cancer, next most common overall, probably the most common in men, about 15 to 20 of metastatic tumors. These tend to be osteoblastic, So lower rate. of pathologic fractures. These do

tend to be somewhat radio sensitive. And again, there's a whole spectrum of aggression for prostate cancer. Renal cell, this is one of the more technically demanding tumors to remove, comprise

about 5 to 10 of tumors. They exist both as local extensions from the kidney itself, from the primary side of disease And also, you can get, of course, distant metastasis.

The renal cell tumors tend to be highly vascular and osteolytic. And they are classically radio-resistant. Sorry, my son has come in to contribute.

He's welcome.

That's a terrific slide. I've never seen all the data put together as well as you did on that slide.

This is what I tell my residents. This is the

one to take a screenshot of for when you're counseling patients in the ER, just a quick and dirty understanding where these tumors are coming from.

The most salient paper I think to go over with respect to management of spinal tumors is the landmark trial by Patchill, which was published in 2005, which essentially examined the role of surgery

to

separate the tumor from the neural elements. And so this was a prospective randomized study where they took patients and randomized them to either surgery with radiation versus radiation alone. The

study was stopped at interim analysis because it was quite obvious that surgery plus radiation was

beneficial for these patients.

The key results from this study, patients that underwent surgery prior to radiation, 84 of them retained the capacity to ambulate versus 57 with radiation alone.

The patients that underwent surgery maintain the ability to walk for 122 days after the

diagnosis, after the enrollment versus 13 days in patients that had radiation alone

The ability to regain walking function was much higher in the patients that underwent surgery, 62 versus 19 and overall there was much improved pain scores.

Now, this study obviously was underpowered to examine the differences based on tumor histopathology. This study excluded radio sensitive tumors like lymphoma, myeloma, germ cell tumors. They

excluded patients that had been paralyzed for 48 hours So, you know, I think that. You know, the thing to remember, and I'm sure Dr. Osman and some of the senior faculty here can comment, but

you know, prior to this study, there really was a sense of equipoise in the field as to whether or not surgery was beneficial for these patients. You know, there was maybe a sense that, you know,

the natural history of metastatic disease to the spine was so severe that maybe these patients should be validated and not operated on. Dr. Osman, I don't know if you want to comment on that.

No, I just finished my residency. I'm just learning.

Well, we're all learning. Non-screatory was published by Iliya Law for in 2013. And this provides a framework that surgeons can use to help guide decision-making. And, you know, it is truly

something that just, you know, kind of makes common sense, We examined

the neurological status of the patient in the likelihood of the tumor to cause neurologic compromise. Of course, we consider the tumor histology, the sensitive to radiation therapy, as well as

other systemic therapies. We assess the mechanical stability of the spine with the sense criteria to determine whether or not the patient needs surgical stabilization. And then, of course, we look

at the patient as a whole and consider the systemic burden of disease And we use this framework to decide whether or not patients should undergo surgery.

Along with the non-criteria, when considering how to take care of patients with epidural spinal cord compression to Bill's key, scale is useful. The Bill's key scale considers patients with bony

disease being grade 0 and then patients with severe cord compression, no CSF signal being grade 3. And in between, there's varying degrees of decal sac deformation, chord compression with CSF

still visible. And then, again, the spectrum all the way up to grade three. The thing for our surgeons here to know is that patients with grade two and grade three types of compression, generally

speaking, benefit from separation surgery followed by adjuvant radiotherapy. So grade two and grade three are really the ones particularly for radio resistant tumors. Patients with grade zero,

grade one, grade one B, grade one C, may not require separation surgery particularly for radio sensitive tumors.

What is separation surgery? So separation surgery, and we'll go through a case example, separation surgery is, a neo-agivant surgical resection and decompression of the spinal cord prior to

radiation. And then the goal of that is to remove tumor that's in close proximity of the neural elements, decompress the spinal cord. And that accomplishes two goals. Number one, of course, it

decompresses the spinal cord to maintain neurologic function. But number two, it actually allows you to give higher doses of radiation to the remaining tumor. If there's tumor that's in close

proximity of the spinal cord and you give a high enough dose of radiation to affect a biological effect on the tumor, unfortunately, there's gonna be higher risks of radiation myelitis. So getting

the tumor away from the spinal cord prior to radiating it, that's the idea with separation surgery. And that presupposes the capacity of austereotectics.

Regis surgery, correct?

Yeah, it's a good point. Yeah, SBRT, IMRT, SRS, classically, yeah, that's the presupposition is that you have access to that type of technology. But I think even for external beam

radiotherapy, there's certainly value.

One could argue that there's maybe more value because you have to have higher overall doses with external beam radiotherapy to get control of tumor.

Just kind of curious for my own learning. What is the utilization of SBRT, IMRT,

and SRS? In Sub-Saharan Africa? In Sub-Saharan Africa. I couldn't come and I'll have to ask. We have to ask Sam What's

your experience? And Nim isn't here today. He could give us his sense from Kenya. Well, maybe Ben could, but Sam, Sam and Ben, what could you two comment on that?

Very limited experience in that. Of course, our facilities are the therapy service. It's not very robust. Most of the time, we're in scale sending pictures for the therapy because more harm than

good is achieved. And that's why, with the quality of the therapy we have, we still not, not at the level you enjoy in developed countries. And I really don't. Yes. I'm around. I'm here today.

Oh, name, I'm sorry. I didn't notice. Yes, I'm here. I don't know. I'd like the, there's Dr. Kibwe, Julius Kibwe I see him. He's the head of neurosurgery at the university where I used to

be. Dr. Kibwe, are you on the, on this call? I see your name there. Yes, thank you, I'm on, I'm following up. Why don't you give your comments about the radiotherapy or use of radiotherapy

on it? Yeah, radiotherapy capacity in your. Oh, yeah, it's a stereotype of a stereotypic in IMRRT. The

radiotherapy is very much improved in aerobic and we have

studio static radiotherapy and Lina and Lina, and we also had a cyborg. And most of the metastasis, depending on the number of levels we have, of course, we use also our spinal tepidic colleagues

with neuro, most of the times and times to manage pain or to manage the deformities, who sometimes decide to fuse. And then obviously, we have very good oncologist, we

live in targeted therapy. So depending on targeted or immunotherapy and the advice is in chemotherapy, you combine these accommodations. So with the multidisciplinary approach, we are tending to

have very good outcomes. Of course, the fusion sometimes depending on the instability

is what a lot of decisions has to be made. We have what we call multidisciplinary committee where cases are brought up and they are discussed thoroughly, including the teams of the primary physician

or doctor, the neuroscience and oncologist, and we make up the appropriate decision. But the surgery and the radio therapy has really improved and depending on the case and the decision, then you

make up the right call. Thank you. Thank you so much. And you mentioned the availability of lean act. Is that

beyond Nairobi as well Is that restricted only to Nairobi and people who have. It's beyond Nairobi also. We have several centers about maybe two, three hundred miles out of Nairobi, which is also

a center of excellence. But most of them are also in Nairobi. We have also around the Mombasa, what you call our eastern side on the Indian Ocean. So the advantage is

in the machine and bringing in new technology is really improving in terms of the country. Thank you. Thank you. Thank you very much, Jay Morgan. Jay's in the United States as in private practice

in Reno. Jay, what's your experience in this area, metastatic tumors to this point? I think it's very similar to what's being presented by Dr. Vibis. We try to get tumor away from the spinal

cord and then get radiative surgery if you can of the breast cancers that are widely metastatic in older women. with a fairly stable alignment. We may give radiation therapy too and not get into

surgery because the bone is not terribly good. Decompression for prostatic CA is something that we'll do if somebody has

not neurogenic claudication, but caught a quenus syndrome, but the law can be treated with chemotherapy. And for the vascular lesions, we'll give a pre-operative embolization, possibly first,

and then try to do wide resection and instrumented stabilization.

So there you go, Andrew. There's a view across the world of how the different people treat things depending upon when the equipment and all the things they have. Yeah, yeah, no, that's fantastic.

I've got the slide for the SIN score. I'm sure everyone's heard of it or uses it. You know, the SIN score is a way to categorize pathologic fractures as being stable and determinate or unstable.

Again, these are things that make sense, but it takes into account the location of the fracture. Obviously fractures that occur in the rigid spine or semi-rigid spine are less prone to catastrophic

dislocation, whether or not the patient has pain, the quality of the bone within the pathologic fractures like liddic, is it plastic, et cetera. And so the sin's criteria in combination with the

bilsi scoring in combination with the noms criteria, those are really the things that we use to guide treatment

decision-making to guide us either towards neodymant radiotherapy, separation surgery plus stereotactic post-operative radiotherapy or surgery alone So again, this is the.

integration of the non-criteria with

syn scoring, just kind of showing you how we approach these tumors.

This is essentially the algorithm the algorithm adopted from Ilio offers paper from the Oncologist

2013, but you guys can refer to that paper and take a look at it I'm gonna skip over this. This is the Tocahashi scoring system. I included a couple of the scoring systems, the Tomita, the

Tocahashi. These are useful in terms of getting an idea for how long patients are going to live with their metastatic disease. Obviously, if you feel like somebody has less than, less than two to

three months of life, then probably those patients are gonna be managed not operatively. uh, with palliation. Um, last but not least before we get to our cases, uh, primary bony spinal tumors.

Uh, this is a passion of mine and one that I take, uh, take a lot of care of, but I'm going to go through this very briefly because I think the case based discussion and then, you know, of

course, we'd like to get to that, um, metastatic tumor that the, that the residents have, but broadly, Cordoma, Condrus, sarcoma, giant cell tumors are the spine. These are the most common

primary, uh, bony tumors that, that I deal with. Um, and again, these will be there, uh, within the slides for, for, uh, anybody that wants to, to see these slides. Um, gonna move on to

just a couple of clinical cases. Maybe we'll, we'll do, uh, one or two of them. Um, 64 year old woman presented with a history of coroidal melanoma. Uh, she underwent a nucleation about two

years later was found to have metastatic disease. She presented with mid thoracic back pain that was worsening after exercise, who's found to be neurologically intact.

And so, you know, for our residents or trainees in the audience, I suspicion for pathologic fractures when you have a patient with prior metastatic disease who presents with back pain. So imaging

you'd like to order, most likely start with some x-rays. You know, full-length standing scoliosis x-rays like a 36-inch plate is nice if you have access to it, otherwise you can do surveillance

cervical thoracic bumbar x-rays. Eventually, all roads are probably going to lead you towards getting an MRI, but depending on the center you're at, you may get a CT scan prior to.

This is what the imaging demonstrated. So, you know, we've got Metastatic lesion at the T9 level looks like it's based within the lamina. extending into the right-sided pedicle, probably into the

cost of transverse junction and the transverse process a bit. And you can see that this tumor does expand the bone into the epidural space causing core compression. This is probably would be

categorized as a Bill Ski II tumor.

In terms of sin scoring, you know, the location of this in the semi-rigid spine thoracic. So no points for that The patient does have mechanical pain. This is a mixed plastic tumor. I didn't show

you the CT scan. It's coming next, but there's a large liddic component to it. No vertebral body collapse. There is

postural lateral involvement, involvement of

the posterior element. So this is overall a sin score of probably five or six indeterminate. Those of you that use the sin scoring are gonna find out that most of them tend to be indeterminate So

how useful the

synscoring is can be debated. But ultimately, this is a patient with cord signal change. This is a tumor that's relatively radio resistant. And

here's the mixed litic component of the tumor. So this is somebody who in our center would undergo a separation surgery, a resection of tumor followed by subsequent adjuvant SBRT And so skipping

over this just for time's sake, but separation surgery plus serotactic radio surgery. My practice is to do these through a minimally invasive approach. So this was performed with tubular access.

So metrics tube in order to perform the lemonectomy, resection of the transverse process and pedicle, as well as resection of the tumor itself.

And so this is our post-operative imaging, showing a gross total resection of the tumor, very minimal unilateral approach to this, minimalist unilateral approach to this. This patient was

discharged on post-operative day one, did very well, had improvement in her pain. And then subsequently we are able to treat this patient with stereotactic radius surgery, 24-grain a single

fraction, you can also fractionate to three fractions.

And you can see that our ability to contour this spinal cord and deliver very high biologic doses of radiation is much improved after getting the tumor away from the spinal cord.

Well, vascular was it? Not too vascular. I haven't seen a tremendous number of these you veal melanomas, but they seem to.

are gonna have a high risk of wound complications. You wanna radiate them as soon as possible because you don't want the tumor to recur. Obviously, and I've seen recurrence of tumor even after,

you know, one to two months. And so, you know, the likelihood of that wound falling apart is very low. It's a small, about a one-inch incision.

You know, we can get these patients out of the hospital same day or next day and get them to radiation within seven to 10 days So that's the main value add for approaching these in a minimally

invasive fashion. Good answer. Jim, why did you assume that it would take longer to do it minimally invasive? Well, he said that he had to take a long time to get hemostasis and so working

through the tube. So I assumed that was the reason. Yeah, this case took about two hours, two and a half hours.

overall doing okay with with systemic therapies. You know, with in the new age of immunotherapies, people just, you know, there's there seems like there's always a targeted, you know, therapy

that's available to people. So, but great, great question. Thank you. Let's go ahead and move to another case.

I tried to go heavy on the metastatic cases here, strata per discussion

So, this is a 70-year-old male who presented to me history of non-small cell lung cancer, stage 4B. This does have a targetable mutation with an EGFR-X on 19 deletion. It was diagnosed via

bronchial biopsy He does have metastatic disease in the liver and the ribs. He He, uh, had actually an excellent response to Tigriso, which is one of the immunotherapy options, but unfortunately

developed significant lung toxicity. He was on a prednisone, 60 milligrams daily and on five liters of home oxygen at baseline. So this gentleman presented with left-sided thoracic back pain for

two months, pretty significant pain.

And he has, let's

see here,

this is the lesion that he presents with. So on the left panels, we see two-weighted images, fairly large tumor that looks to originate from within the pedicle on the left side, the extension into

the cost of transverse junction involving the rib head, a little bit of extension into the retroplural space involvement of the left lamina transverse process and probably some involvement of the

paraspinal muscles here. In terms of the spinal cord, there's effacement of the spinal cord,

again, a Bilski II lesion. So there's compression of the cord, but still, you know, CSF around. You could maybe argue that this is a Bilski

1C. But so this is a patient now a little bit different since scoring because there is disease at the thoraculum bar junction. You can see on that sagittal CT that the entirety of the facet complex

on that side has been destroyed by the tumor.

Ultimately, this is somebody who was taken to surgery for a separation surgery. We resected the tumor, achieved a gross total resection, lemonectomy, pediculectomy, costar transversectomy,

extra cavitary approach to resect the disease that was within the retroplural space

our center, we do have access to carbon fiber. instrumentation, which can be useful for patients that are going to undergo subsequent stereotactic graded therapy. So this is the carbon fiber

instrumentation from iCATEC

and uh

being aggressive with this cancer, because it had this targeted, targetable mutation. So these cancers, you can get, you know, 40, 50, 60 survival at five years. If they can tolerate the

immunotherapy, this patient unfortunately just did not tolerate the immunotherapy well as lungs took a really big hit, and

I think ultimately had we just gone to radiation alone, I'm not sure whether we would have gotten control of

this disease with radiation alone. It was a pretty large tumor in multiple compartments But I do sometimes wonder if I had just done a kind of a separation type surgery, not as big of a surgery,

maybe we would have gotten away with it.

So your propensity to miss recurrent disease around the periphery of the hardware is higher with titanium. Per metastatic disease, the value is very, very much uncertain.

I would say that if you don't have access to this instrumentation, which I didn't have access to it up until recently, I think the thing to remember is to try to minimize your implant density So try

to keep the number of screws, particularly around the area of the tumor to a minimum. Your radiation oncologist will hate you if you use you a lot of cross links, the cross links make it very,

very hard to do a stereotactic radiosurgery and try to avoid multi-rod constructs.

Those would be the tenets. I don't have as much experience using laminar fixation, but if you have access to, you know, laminar bands and things like that. I've been told those have much less

artifact. So that's a consideration as well.

Okay, thank you. Perfect.

Do you wanna try to

go through one more case or should we have the resident present at this point? I know we're coming on time. Sure, well, yeah, let's Sam, is your resident from your shop prepared to do a

presentation?

If he has another example, let him go ahead. We still have time. Okay. Okay. No, my pleasure. All right, let's move ahead here. So the teaching point there is, you know, patient selection

for these patients with, you know, metastatic diseases is

critical.

a three-level ACDF with me for correction and their deformity. Let's see. I'm

going to skip over this one as well. That's a meningioma. I'd like to get to this last one. Okay. This is

a 24-year-old male who presented out of history of B cell lymphoma I had undergone induction chemotherapy. I'd had some extramagillary relapses, but presented with regressive bilateral low extremity

numbness with a T6 sensory level. No weakness initially. He did have anrogenic bladder in the emergency room.

This is your neurologic exam. He's essentially full-strength, maybe some pain limitation in his hips, a T6 sensory level, No upper motor neuron findings.

any other histology, if you're looking at a lung tumor, prostate, you know, whatever, you know, this is probably an operative lesion, but things like lymphoma, they are exquisitely radio

sensitive and these are patients who can get radiation upfront with a dramatic improvement in their

burden of disease. I included the dates here just because, you know, I think there's always a question when somebody has a neurologic deficit. Yeah, fine, maybe radiation will work, but they've

got a neurologic deficit. We need to get the cord decompressed immediately. So in this patient, you can see that the MRI on the left side was from September 22nd, 2024 with the severe cord

compression. This patient got radiation on September 23rd,

September 24th,

you know, we re-image the patient three days later, two and a half, three days later. And you can see that already the cord is well decompressed, the volume of tumor in the epidural space has

been dramatically reduced. And then, you know, long-term follow-up, April of 2025, you can see his MRIs is effectively normal. So, you know, and clinically doing very well, walking

independently known neurological issues, doing quite well. So, Andrew, for the sake of discussion, if this patient had a T6 sensory level, but

was intact motor-wise, if this patient had presented within 24 hours paraplegic with loss of bladder and bowel function, would that have altered your thought process? Yeah, I think so, you know,

I think, for me, you know, I know that these tumors are going to respond really quickly to radiation. I know within one to two days, they're already going to start to see some effect, and this

patient has an exam that I can follow, right? He's five out of five strength. Yes, he's got the neurogenic bladder. I'm concerned about that. Yes, he's got the sensory level. I'm concerned

about that, but his anterior columns seem to be working. Okay. This is, you know, his symptoms are mainly from the dorsal column compression That's an exam that I can follow.

There's a non-zero chance that this tumor hemorrhages during radiation, and that can precipitate, you know, catastrophic worsening of the neurologic exam. So we're keeping a close eye on this

patient, and we can always pull the trigger and take him to surgery. But that's different than someone that comes in with a devastated neurologic exam. I think in that instance, you don't wait on

it. You take it to surgery, you decompress the spinal cord

And I show this case because I think it is.

No questions, you mean?

Have you had the presentation from your place and then we can have further discussion? Okay, I don't know. We check. All right, I thought there was somebody before him. All right, I'll check

what I said, hello. Okay, if not any questions otherwise for Dr. Vivas. Again, thank you, Andrew, that was very well done.

Andrew, this is JN. Morgan, can you hear me? Yep, I hear you well. Yeah, so if you had a 45-year-old. I already wanted to present it, but. A 45-year-old man with an appendomy. What's the

number 10 in jail? At C3, who was relatively asymptomatic. Would you follow that along or would you take him to surgery? I would take him to surgery. You know, at Pindomoma, it's

different than meningioma, different than schwannoma in

that. The natural history of it is one of progression. I mean, there have been angiomas, Jay, I'm sure you, you like me, like the rest of us. Sometimes you find them an angioma, you wash it

for like 10 years and nothing happens. You know, it just kind of hangs out. I've not seen an ependomoma that behaves in an indolent fashion like that. Now, there's probably a distinction between

ependomoma and sub-apendomoma, which we didn't get into. Those may be a little bit more indolent, but in general, I would say that take it out when it's small. It's easier if there's less

neurologic risk if you're sure that it's an ependomoma. Now, if the imaging characteristics aren't classic, maybe it's not enhancing, you think maybe there's a sub-apendomal component to it,

that's one that maybe you wanna watch it a little bit. You certainly, there's no urgency or emergency to taking out an ependomoma.

For me, actually, if it's a mixopapillary appendomoma, I'm more willing to let that then grow up and get big, because even if it's a big tumor, I think I can take it out safely usually. But at

the cervical medullary junction or C1, C2, C3, once those things get big and start to cause respiratory compromise, those are scary cases. Those are cases with a high surgical morbidity. So I

think it all comes down to do you want to front load all that risk to the day of surgery or do you want to

kick the can down the road and potentially have a higher risk later on? And for a 43 year old, I mean, there is no question in anyone's mind that that tumor needs to come out at some point, right?

Like he's not going to live another 40 years and not have a need for surgery. And if you wait until he's myopathic or you wait until he's got

a bunch of cord signal change spinal cords angry,

then it becomes a pretty risky surgery and a tough recovery. So that's just my own perspective on it and maybe that perspective is somewhat informed because I see a lot of people that are referred to

higher level of care and people have been sitting on the tumor for a decade and then by the time it comes to us, it's like, man, I wish someone had taken this out five years ago Thank you very much

for that, Andrew. So Dr. Kibwe, you have your hand raised? Yes, thank you very much and I

was asking, Andrew, thank you for that discussion. I was asking, Andrew, what do you experience even with the norms in patients who have spinal metastasis? And then they also have

brain metastasis, maybe one or two, what would be a change of taktik. And then I've had a situation where I picked and typed them.

you know, a liver met separately from the spine met.

What I would say is that it probably does figure into just the consideration of the overall systemic burden. Now, if somebody's got, you know, can-and-balled mats, you know, they've got 30

metastatic tumors in their brain, I'm probably disinclined to pursue, you know, aggressive surgical therapies in the spine.

You know, at our center, we're doing stereotactic radio surgery for two, three, four, five, sometimes as many as six separate foci of metastatic disease in the brain. And we've got, you know,

excellent control rates with stereotactic radio surgery for these brain metastases. We don't run into the cognitive downsides of whole brain radiotherapy. Even hippocampal sparing radiotherapy

has a lot of cognitive downsides. So I'd say we're pretty aggressive with the brain metastatic disease here and. you know, provided that it's one or two sites, you know, I think it would be

reasonable to

be aggressive.

In terms of the child, you know, I, gangly on the aromas, you know, intra within the CNS, it's a pretty rare disease. You know, I can take care of a lot of tuners. I can count maybe two or

three that I've seen.

Neuroblastoma and children, obviously much more common It's tough to say without looking at the slides ourselves, but I would say my best guess is, I've not seen a

ganglid neuroma have malignant degeneration and conversion to a neuroblastoma. So my best guess is that it was a sampling error with the first specimen. Maybe not necessarily that the pathologist

was wrong, but sampling error can occur.

would be my best guess. And then the last one, my experience with plasma cytoma and multiple myeloma, you know,

for better or for worse, you know, I think we're seeing patients with multiple myeloma live a lot longer. And they're very challenging patients to manage because, you know, commonly they'll

present with multiple compression fractures across multiple contiguous levels, and the bone density is horrible. You know, the DEXIS scores are in the three minus threes and fours. Very hard to

stabilize. Even if the medical oncologists can get relatively decent control of the systemic disease, it's very hard to manage, manage the structural implications in the spine. So plasma cytomas

are great. They're, you know, my favorite cases, because I think the patients do do well and you can treat them well, but the patients with more diffuse, you know, disease, multiple myelomots.

is that you've developed this by pursuing an area that most people ignored in the past and gave up on into one which there's hope and promise. And I think you've done a great job. Thank you, Dr.

Ospin. Yeah, I think cancer care is rapidly evolving in all sets, right? I haven't been doing this forever, but even in the 15 years, since I have been doing this, the treatment paradigms have

rapidly evolved. And I operate on things routinely now that when I was in training, nobody would have operated on. So, for whatever, that doesn't mean it's right. But I would just say that the

paradigms are rapidly evolving. Well, I mean, I think to Jim's point, and you asked this question about the impact patch of paper. I think that was that was a game changer, because I remember

how after that time we started getting many more referrals, because we didn't see a lot of those tumors, because people assumed that

a surgery was not a significant factor to alter

the outcome, and then with the advances in spinal surgery, we've been able to do much more than we were able to do when I was in residency in the ancient era.

Absolutely.

All right, do anybody have any questions or thoughts or?

I wanted to ask him. Hello. Yeah. Go ahead, Sam. Yes, Sam How do you manage quizzes that present late, and somebody has come with their multiple lesions already lost a string to function?

patients that come in with neglected disease like that, it's because truly they've lost the will to live. They're not really interested in being highly aggressive about their medical care. If they

were, they would have sought care earlier, not blaming the patient, but just getting a little bit of insight into what their mindset is. But I would say this, I think that

the goals of surgery evolve at different stages of the disease Early in the disease, the goals of surgery are to maximize neurological outcomes to control disease as long as possible, of course, to

affect a surgical cure if that's in the cards. In later stage diseases, particularly in people that have neurological compromise, the goals of surgery evolve. We know that the length of their life

is not gonna be impacted by the surgery, but can we impart some quality of life for the remaining time that they have. Can we improve their neuropathic pain? Can we improve their biomechanical pain?

Can we preserve their bowel and bladder even if they can't preserve ambulatory function? So those are the questions and considerations. But I think the key to remember is that

when you're talking about surgery for metastatic disease, the surgery itself is unlikely to extend the quantity of life of the patient So surgery is not a cure for metastatic disease. We're talking

about preserving function and quality of life. So if the function is already gone and there's no improvement to be gained in terms of quality of life, then in that instance, surgery may not make

sense.

Very, very good answer. Sam, was that satisfactory? As such, I thank you so much because many of the officials are expectations are high. Once you say treatment, they expect that they will

cover, they will cover the lost neurological function. But I think that that approach is said.

Thank you, that was good. Okay, Dr. Gima, any questions you want to have?

Professor Gima, he had

a case to do, okay. All right, that was just a terrific job Andrew, there's two things missing. One, I didn't see your name in the reference list.

You should write up a review. And we publish an instance in surgical neurology international, I think it was, you did a great job. And we'd like to have you back and talk some more if you'd be

willing to do that. Oh, I'd love that. I very much love to hear some lectures from our colleagues around the world I'm very passionate about.

at the Defense Forces Hospital just outside of Kenya. Well, let me introduce Ben Matisseau. He's Dr. Matisseau is a consultant in the research and at the Defense Forces Hospital in Nairobi. Ben

has presented with us before and he's going to have a discussion on post-operative spinal leopardural hematoma. Thank you, Ben. And thank you for your patience and for agreeing to do this today So,

yeah, so I'll give a short presentation on

post-operative spinal leopardural hematoma. And this is a case that we recently did. And I thought that I would share

the kind of experience that we got from it. to get the opinion of colleagues on this forum. Yeah, so our patient was a

79 year old female and she came to us with bilateral

upper limb weakness that had been progressing for the last six months before she came to us. And she also had some disturbance in her gut as well

When I examined her, she was

hyper-electric and spastic in the extremities and she had reduced power in the hands such that she could not have a

proper grasp whenever she would try to hold on to something. And of note is that this patient was also hypotensive, but

she was not on aspirin or any anticoagulants would increase high risk of bleeding. So I send out for an MRI scan, and this is an MRI scan. And from this, we see that she has multiple level disc

disease, all the

way from C3, C4, to C6, C7.

So that's about a four level disc disease.

The slides are not moving. Oh, they're not moving? No, please

Yes. OK. There you go.

OK.

Yeah. So she had -

so we did the MRI that showed that she had the multilevel disc disease that was extending from C3, C4, all the way to C6, C7. So this was about a four level cervical disc disease. And we could

see that there were spinal cord changes with myeloma alaysia, especially at

C3C4. So, I don't know what the opinion of the people here would do with this kind of a case when you have when you have multiple levels of like a disc disease with myeloma alaysia in a 71 year old.

But my opinion and that of my team was that we would do a posterior survival called the compression with fusion, with lateral mass screws and

rods all the way from C3 to C7.

And we took her through this surgery which was uneventful and in the immediate post-operative period she had a good recovery and she returned back to baseline to what she was before we took look at

surgery, and after surgery we did not put a drink.

Well, yeah, if you feel that we've achieved adequate hemostasis and by the time that we are done with a good minute of pressure,

we don't routinely put drains. But I would say that this has a lot of intercygion kind of variation, such that there are those people that will always put a drain. And there are those that, you

know, will put a drain sometimes just depending on how they feel

about the surgical bed at the time that they're closing. Absolutely, yeah, makes sense. So

for discussion, so we, the seems to me, there's quite a bit of anterior compression. And so are there any takers for doing an anterior multilevelity, anterior decompression.

As a first decision, maybe subsequently coming back and doing something posteriorly, depending on the situation. Any takers for that?

As opposed to a posterior approach with either laminoplasty or cervical posterior decompression with lateral mass fusion.

Hey, Strata, this is Jay, I'll take it. Thank you, Jay.

I do a C3-4, C4-5, C5-6, ACDF and maybe leave C6-7, but I'd have to see the axial on that. But I've done four level anterior cervicals on patients and they've done okay. 71's not

in the age range where they think that they get the difficulty with swallowing and so forth to a greater degree, so

So, I haven't had a big pseudo-Earth versus problem.

I appreciate it. Yeah. So, I think anterior prostate is also an option in this patient, but yeah, I think one of the concerns, we actually thought about it, but then we would, but then we saw

that there is also a significant compression from posterior especially at C3C4, and then we thought maybe we may not achieve adequate decompression from anterior approach only, but I think it's

worthwhile trying.

Yeah, so

the patient did well and was transferred back to the ward, but however, about the use of

post-operative drain. Andrew brought that up

Are there any others in the audience who want to weigh in on the utilization of drains, whether to do that routinely or do that on a select basis? I must admit that in my practice, I didn't

routinely use drains and dependent, and I'll try to be very meticulous about hemostasis. And only if I thought about using a drain, then I would use one So, any other comment about that topic?

Well, Andrew would want to tell me that I'm crazy. No, no, no, I don't think you're crazy. You know, it's interesting, in our country, there's a huge push towards doing everything outpatient.

Everybody wants you to do everything in the surgery center, outpatient, the insurances. They won't cover the inpatient hospitalizations anymore. For patients that I'm going to be keeping in the

hospital for at least two days anyways. I tend to leave drains.

Okay, thank you.

Ben, please proceed. Yeah, I'm sorry. Right, yeah. Okay, yeah,

we can have some, yeah.

Yeah,

for the drain, we routinely put the drain for procedure approaches. For the procedure, it depends on the type of problem. The common entities, the patient has. Laminoplasty is, we do it

commonly If we feel worried about the patient's cell or their common entities, and our own laminoplasty is modified. It's not the classical, that's used the same plant and so on. We do it in one

that does not require any implant use and we usually drain, in such cases. I don't know the age, I miss the age of the patient. How? 71 session this is old.

Yes, that is a good question. Let me know, plus the particular there's substantial pressure on the compression. Multi levels.

but we were not satisfied because we could see that the patient is not doing well, so we requested one agent MRI as well, and this is the MRI that we got. And

the radiologist actually told us that there was severe spinal lastinosis with worsening of the spinal quality, but did not mention,

but did not talk over hematoma

So, he didn't actually say that there was

a hematoma. But what we saw is that there was this

hyper intensity, both on T2 and T1,

that was within the surgical bed, and there was severe subacles, spinal canal stenosis with the

placement of the CSF space here.

and with increase in the edema within the cervical, within the cervical spinal cord.

So we had initially thought of this by the white cord syndrome, but then when we saw this, we said we have to explore the wound and see whether this could also be a hematoma, even though this has

not been recorded by the radiologist.

So we took our back to surgery as soon as possible. So this was about maybe now seven, eight hours after surgery is when we were getting back to the operating table. When we got back to surgery,

this is what we found. And you see that, and this is the incision. And these are the suboxypptomassos. And then you see the plot just beneath the suboxypptomassos. These are dense hematoma that

was firmly compressing over the thickest sack. And we have acuted the hematoma And the photo on the right here, after we have evacuated And you see the implants are in place, they are the lateral

mass cruise and the thickle suck was adequately decompressed. We found that there was some oozing from this point that we put

SAGI cell from one of the epideral veins.

There was just a slow leak, which you thought maybe it may have been the sauce or it may not have been, but yeah, that's the only bleeding point that we found, but we had to wait. After we did

this, we had to wait for another, just 20 or 20 minutes just to make sure this does not come back again. In this particular time, we left a drain.

Yeah, so she did well after SAGI and by the, in her function, improved gradually,

So, I don't know before I go to the discussion if we have any questions or comments about the case

that's a great safe. I'm so happy that she got back to normal. I mean, these epidurals, they're going to happen. If you operate enough, you're going to get some epidurals. I think that big

question in my mind is whether or not this was going to happen, whether you left

the drain or not. My impression, just from discussions with people, is that if there's something that's bleeding rapidly enough that you accrue a hematoma of that size within a few hours, the

drain may not be enough to save you. It may be something where the drain would delay the presentation, but ultimately this may have happened with or without the drain.

I don't know. It's kind of the same discussion points we have with leaving drains for subdural hematomas. Right, I've got some of my partners that don't leave drains for subdurals ever. As they

say, if it's gonna recur, it's gonna recur with or without the drain. It's not gonna change the, it may change the time course, but it won't change the ultimate natural history of it. It's gonna

happen 30 of the time, whether you leave a drain or not. So I think it's an interesting discussion point.

I don't know if anybody knows, but there's been a couple of studies that have compared the rates of epidural hematoma with or without drains. Nobody has ever demonstrated that drains decrease the

rate of symptomatic epidural hematoma. Most of

those studies have been done in the Lumbar spine, not the cervical spine, but I've always found that curious.

Yeah, so there's a hand raised Josh. Yeah, I completely agree with you. Okay, yeah. Josh Roviti, please, you have a question or comment?

Well, in most cases, you're going to take maybe a day or so. Forget it, MRI. Would you go back in and just explore? Or would you insist on getting that MRI before you go back in? I think that's

an excellent question. And

I think

time is of essence. And one would not

be fault if somebody, after a procedure like this had a deteriorating neurologic function, what would not be faulted for? In fact, I think it would be judicious to take them back to the operator

room for exploration. I'd be interested in other comments.

Yeah, I would agree 100 with that, Estrada. This presentation actually is classic for epidural hematoma, which started with

sensory deficit in the arms you know, progressed to, you know, rapidly progressed to quadriparasis. I think even at my center where we can get MRIs, you know, within four to six hours, I may

have given consideration to just taking her back for an exploration. At my center, despite all the bells and whistles, we don't have an MRI tech overnight. So in order to get an MRI overnight, I

have to call the consulting radiologist and get them to agree that the index of suspicion is high enough that they should send the tech to the hospital, which takes oftentimes, you know, one to two

hours and then to get the scan takes another hour. And that's valuable time, as Estrada said. So in this patient, if all of this was happening at two to three in the afternoon, yes, I would have

given the MRI and I would start preparing the OR for the eventuality of us coming back Um.

The other thing is, in these acute post-doc cases, I must say that

I've tended to find imaging unsatisfying. And scratching my head, you know, in the

CT, not so good as MRI. And then the MRI, you have oxyhemoglobin in the first 24 hours or so, and the blood is sort of iso-intense And

I usually found myself wondering what - how much was there and if there was something there early on with the MRI, looking for hematoma.

Ben, if you want to. Yeah, I completely agree and I think after having gone through this case and the kind of experience that we had and even seeing that the imaging,

I don't know if I would say that it was very useful, you know, like,

yeah, because the radiologist fast did not actually detect the hematoma, he just spoke of post-operative changes and

so we may not, I think the clinical diagnosis and the suspicion could be the most important and

really what saves the patient because also time is of essence here, you cannot wait for too long

Yeah, so I think we'll go straight forward to the discussion and this

and post-operative spinal epithelial hematomas are rare.

So that's an important one to note.

If you intervene within

24 hours, if you intervene before 24 hours, then 66 of your patients are going to have a complete recovery. But if you delay your intervention by more than 24 hours, then only 33 percent of your

patients are going to have a complete recovery. So time is crucial when you're treating this

pathology. The risk factors include lumbus surgery, it's more common in the lumbus spine, and patients with high tension, patients who have had unsafe use, and long segment surgery, patients who

have quite a lot of these, and also is more common with posterior approach, and if the patient is more than 70 years old Just from this we can see that our patient had multiple risk factors, that

is a preoperative high potential. the long segment surgery, the posterior approach, and more than 70 years of age. Do drains reduce the incidence of symptomatic epidural hematomas, there's no

evidence that they reduce the incidence like has been discussed before, and the similar incidence for patients with or without drains. The only difference in patients that have drains is that the

size of the

hematoma is small compared to those that have drains, but that does not seem to be any direct clinical benefit of this, and additionally drains also increase the risk of surgical site infections.

They will also increase

the postoperative blood loss and potentially have a longer hospital stay, so these are maybe some of the downsides of putting a drain, but this is a highly dependable topic and I know you know

people there are those people who will always put in a drink whether we have the evidence for it or not and obviously this is quite a heated debate that we can discuss about

yeah

there are other risk factors that you that one would imagine is the use of postoperative thromboprophylaxis the patients who have been instituted on postoperative thromboprophylaxis have a higher risk

you know the patient that you start on plexin at 24

hours after surgery today have a higher risk compared to the one who is not and there is no evidence that that that is a risk factor so your thromboprophylaxis does not increase the risk of the

epidural he not almost again so the take-home message is that we should have a high index of suspicion and then and we should make the diagnosis promptly and once we make the diagnosis then

questions. Joshua, is there a question? Yes, please, Joshua, go ahead.

That's my mistake, sorry. Okay.

Any other comments? Andrew, is that budding neurosurgeon listen to this? So listening so he can get these key points for his future career?

No, I guess my only comment would be, listen to the patient, listen to the patient, examine your patients, go see them with your own eyes and make the decision not the one that's convenient for

you, but the one that makes the most sense logically, which I think we'd all agree with.

I did review the chat here. Some people had reached out via the chat to request the presentation and sent me their emails. So I've gone ahead and sent that presentation to the folks that requested

it. Estrada, Dr. Ausman, I also included you on that correspondence. I was able to send a PDF. I wasn't able to send a PowerPoint because it's like 80 megabytes, so it's too large to send via

email. But feel free to use it to educate your trainees or as a resource. And of course, if there's anything I can do, please, please don't hesitate to reach out And I'll include my email address

here in the chat as well. Feel free to reach out to me if I can be of service. Thank you. If that's all you with you, Jim, I don't know. Maybe perhaps

Mike could put it on, SI Digital, the entire PowerPoint. I don't know if your thoughts are, maybe we can talk about it. Yeah, we can either do anything. We'll talk about it and everything.

Come back and present it to

the rest

Do you have any comments you want to make?

I just wanted to ask, do they prefer MRI

or CT post-operatively, particularly after spine surgery implant?

Yeah, I would say for myself personally, there's so many different logistic considerations.

I think you can identify a hematoma on CT.

The thing to remember though is that the density of the blood on the CT is going to change over time. Hyper acute blood is going to look different than sub acute blood. It's going to look different

than chronic blood. But the thing that I look for is really, you should be able to get a good view of the spinal cord itself, you know, and even on a CT scan, if you start outside of

the surgical area and find the spinal cord on the axial views, follow it up. You should be able to see, you know, hypodence ring of CSF around the cord all the way up if there's no cord

compression. So I guess even if you can't specifically see the blood on CT, you can see an indirect result of the blood, which is the effacement of the spinal cord.

If you have access to a CT scan within an hour versus access to an MRI within 12 hours, I would favor the CT scan, you know, get the imaging that you can. I know we didn't have any slices of the

CT. Although the radiologist didn't read it out, I bet we could have, as surgeons, looked at it and said, You know what? There's something there. Let's go take a look. The MRI, likewise, the

radiologist didn't call the hematoma To me, it looks like a classic hematoma on the MRI, mixed intensities of blood, corresponding to the

portion of the blood that's clotted and the portion of the blood that's still liquefied.

Those are my thoughts. Understanding that we have a good neurologic exam to rely on, this is a patient that woke up and was completely fine, and then within four hours decompensated, that's not

really consistent with white cord syndrome.

And so what are the options here? It could be white cord syndrome. It could be spinal cord infarction or it could be hematoma. Those are really the only three things that I can think of that's

going to make the patient have a neurologic, catastrophic neurologic decline like that. And one of those three things is modifiable. And even if I had no

radiographic support to that, I'm probably gonna take that patient back just to take a look, myself personally

Very reasonable. Nam, you wanted to make some comments? I'm sorry. Yeah, so my comment is ready to comment the presenters. Dr. Vivas for this wonderful presentation, very educative. And you

could share it with us through Surgical Neurology International. And then we can all let us log in. I know they're going to give us your presentation, but if you can also share with us the

PowerPoint, not the PowerPoint necessarily, but the PDF presentation. they need to help us also in teaching our residents. And then Dr. Mutis, so you gave a very good presentation, Dr. Mutis,

which is a relatively young neurosajjan and it's very impressive to see a young neurosajjan with actually less than 10 years solo practice, you know, doing quite well from our site. So I'd like to

congratulate him and encourage the other neurosajjans to present because you get a lot of experience when you present in the international audience. And I'd like to thank Dr. Kibwe, who is the head

of neurosajjans now at the University of Nairobi for, and also he has an extremely busy, proud practice here in Nairobi for logging in and assisting in this presentation and the discussions.

Thank you.

Thank you. Any other comments or questions? Yeah, and I want to reiterate the appreciation to both Dr. Matisse and Dr. Viva's for - Okay, I just have one word. Really appreciate Dr. Viva's to

kindly accept this talk because he gave an hour and a half talk at the residence teaching kind enough to comment, teach the other colleagues around the South Africa

Thank you, Dr. Voss. And thank you for recommending that we do that. Thank you, sir.

Okay. Well, we both said okay at the same time. Well, I think that wraps it up and appreciate everybody participation and

we look forward to seeing you again last Sunday of next month.

Okay, thanks Estrada for working on this, arranging it, and it was an excellent meeting. Okay. Thank you all. See you. Hey, Teri guys, bye bye. We hope you enjoyed this presentation. SI

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