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SNI, Surgical Neurology International, a 2D Internet Journal, and SNI Digital Innovations and Learning, a 3D video journal
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in association with the Sub-Saharan African neurosurgeons are pleased to present the Sub-Saharan Africa International Neurosurgery Grand Rounds held the first Sunday of each month
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This grain rounds is devoted to global solutions, to clinical challenges in neurosurgery. The moderator is Estrada Bernard, there is an international audience.
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The second set of talks are on spinal cord tumors in the Kona and Kota Aquina, challenges in the high-income and low-to-middle-income countries.
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Dr. Michael McGaugh in neurosurgery, Dr. Callan, Oniambo
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in radiology, and Dr. Minda Okiyamwa in
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pathology, all of the University of Nairobi in Nairobi, Kenya, combined to make this presentation In addition, there's a presentation from Jay Morgan, who is the head of Sierra Neurosurgery and
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Reno, Nevada.
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Michael Makoa is
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a neurosurgeon at the University of Nairobi. He had training at the Groatshire Hospital at the University of Cape Town in South Africa and worked at the Agacana University Teaching Hospital in
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Nairobi and is
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the Secretary General of the Brain Tumor Association of Kenya.
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Dr. Okuyama is a pathologist and Dr. Oni Ambo is a radiologist on this team. Both are at the University of Nairobi in Nairobi, Kenya.
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Jay Morgan is with Sierra Neurosurgery, a private practice neurosurgery group in Reno, Nevada. He's past president of the Western Neurosurgical Society and the president-elect of the Nevada Medical
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Association. Welcome. This is I think this is our seventh edition of the SNI Digital Neurosurgery Grand Rounds for Sub-Saharan Africa. Dr. Osman is is the leader of this and he hasn't he's not
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able to be here today and so we have Dr. Epstein with us who is the editor in editor-in-chief of SNI, the Surgical Neuroology International Journal and she has great expertise in spine care and and
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will be offering us her perspective on coronavirus syndrome.
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Welcome to everybody and we're after after Dr. Epstein's presentation and further discussion, we'll go with the with the Kenya group to discuss spinal cord tumors and management in sub-Saharan
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Africa. So Dr. Epstein, welcome again. You've been actively involved with us and we love having your participation. Please go ahead and get started Thank you. Now this is exciting. This will
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illustrate the difference in practicing in different regions. Right now, Kenya is a country of different extremes. We have the highest levels of practice all all the way up in the private
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facilities and also in the public facilities. The main issue we have is literally just population based, etc. This is a really simple case, but especially from your presentation, seeing how we
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ended up here, you'll see where there's a lot to go. So we need to think about more about primary health care
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and patient advocacy. and dealing with government, et cetera, because this situation, in my opinion, didn't have to happen, right? So, as let me start the presentation. So, thank you, SNI
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digital for inviting us here. I'm part of the University of Nairobi and the University of Nairobi neurosurgery. We're going to talk about just a simple case of quadaquinas syndrome. My name is Dr.
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Emma Magoja. I'm presenting with two of my colleagues. Dr. Kallen O'Niambu is a neuro-adiologist. Dr. Mendo Kimwa is a neuropathologist and Professor Nimrod Wombe is a neurosurgeon and one of my
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teachers. OK.
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OK, so I'll keep it short and simple, but try and keep it fun. The patient we're presenting today is a 60-year-old female with no-known allergies. Comes from a location known as Casey, Kenya,
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which is not even one of the central areas of Kenya, but it is a big town. She initially presented a peripheral facility with a history of back pain, about three months prior It was gradual in
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onset, sharp. a lumbar associated with reticulopathy to the right, more than the left. She then continued getting progressive motor and sensory deficit. Her reticulopathy was increasing. She
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could localize it mostly to the right side, and she noted difficulty in walking. At this point, she sought care in a peripheral facility where an x-ray was done, and then we didn't have
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information. She went home. When she went home, she noticed that she developed overflowing continents and fecal incontinence, but what worried her to look for more care was when she wiped herself,
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she noticed she didn't feel anything when she was wiping herself. So that was the main issue. Then she continued progressing to inability to walk, which was due to the weakness. She said the pain
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was excruciating, nine out of 10 in the pain scale, and with regards to the weakness, her neurograding was about five. She was not able to ambulate without assistance at all. They were
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attributing it to age as she was about 63 years. The progression in this timeline is about three months. This is the issue that we're saying She was seen in the beginning. Just had an x-ray didn't
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do anything until she couldn't walk and they came now to the big hospital as they like to say
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Okay, with the gut's physical examination, I'll keep it simple. The spine exam, all curvature was maintained, there was some lumbar tenderness and restricted lumbar movements. The paraspinal
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muscles on the right side were also tender. With regards to the motor examination, bulk was normal in the lower limbs, tone was normal in the lower limbs, power was decreased asymmetrically,
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which is important for us. The power was one out of five on the right lower limb, all muscle groups end on the left lower limb, two out of five all muscle groups going to the medical research
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council grading. We'll move on to sensation of note, we didn't get a sensory level, but we did get saddle anesthesia with loss of anal tone and no anycutaneous reflex. With regards to the reflexes,
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she only had knee reflexes of one bilaterally and with the detail and reflexes zero of the ankle, there was no Babinski reflex, which is expected So from there,
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we went on. So the summary of history in totality is we have a 65 year old theme of the three month history of progressively worsening back pain associated with a particular pain to the right leg
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with loss of motor function in both lower limbs and now presenting with urinary and fecal incontinence. Examination reveals limited range of motion lumbar movements with reduced power in the lower
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limbs preserve knee reflexes, loss of ankle reflexes, and reduced sensory examination findings with subtle anesthesia and loss of anal tone. Putting that all together, this is a patient who has
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cardiac colina syndrome who appears about three months late, which is quite sad. What did we do? So immediately we rushed her into imaging, which is what you said. We can see here on the T2
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images. In the central image, it looks like there's compression of the spinal cord at about T12L1 by this lesion, which is here. When you move on to the right, the parisigital image, you see a
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large division which is
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about T12 L1 which is compressing chord and the nerve roots directly. If we continue,
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there we go. You can see it clearly now.
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If we go, you can see the lesion is right here and it's completely compressing all of the nerve roots, pushing it to the other side. This happened according to her over about three months or so.
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Interestingly, the first MRI, which has done the peripheral center, did not mention this lesion at all. All they did was mention a dyscraniation at L4, L5, which points to some of the issues
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that we have. You have to see the neurosurgeon. Is that because they failed to get axial studies going all the way up? Yeah. That's why they missed it. That's why they missed it. So, and if you
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come here with the star image, the star reconstruction, we can see this lesion, which is here right here about T12, L1, compressing all of the nerve roots eccentrically, and you can see a little
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bit of myeloma leisure within the cord itself. Is there some for terminal extension of this that might make it a schwannomer or.
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We didn't see it directly, but given this, we were thinking it. If I didn't put the DICOM images, but that is exactly what we were thinking, if I'm being honest, because as you see here, in our
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imaging, we thought of it's a T12 L1, intra-dural, extra-medal re-lesion that was ISO-intense on T1 with avid conscious uptake, which was eccentric to the right, causing cardiac quina syndrome.
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The first thing we thought of was either a meningioma or a spinal schwannoma, lastly was
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a neurofibroma With that,
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we rushed her to the next available theater and then this is what we did.
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So using fluoroscopic guidance, we aimed to have a, as you can see here, we don't really have markers, but we use the needle from T12 to L1. We want to have a two-level laminectomy that we did
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under fluoroscopic guidance. As we go through, you can see we cleaned and draped patient. We opened and we did a simple standard laminectomy that you can see here.
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Whenever you want to show off is when things don't work, you weren't able to get
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the video from the operating microscope, but you can see our clear laminectomy. This is immediately after the surgery. What we found was a purely extra-dural lesion, extra-dural, extra-medillary
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lesion, which was not extending into the foramina, which was quite shocking for us. So we shifted, we argued if it was possibly a meningioma, but we'll find out what it was later
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So the first operative course, at least, was good. It was uneventful, she was discharged on day three. At present, she's now ambulating with assistance, an increase in neurograding of about two,
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whilst continuing physiotherapy, she's in good spirits, but she is ambulating with a walker at present. With this, I'll go to Dr. Kemmer, we'll discuss the histopathology of what we found. Dr.
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Kemmer.
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Thank you, Mike. Thank you,
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I want to give a chance to my resident Dr. Bure, Dr. Bure, can you present the histology findings?
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To share or just continue. Okay, so for the bio data, this was a 63 year old female has, has been shared by Dr. Magoha, who presented to the facility with lower back pains for three months and
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right low limb weakness for two months with urine and bowing continents for one week So we received spinal cord tumor specimen from the T12 to the Elwad regi on gross, it was our whitish brown soft
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tissue specimen, which was measuring 10 by 10, and was 10 whites on cut sections, and we all we processed in one percent. So, the radiological hello, radiology, we had the T12
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L1 intramidalary, intradural extramidal tumor. with mild enhancement
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and intraoperatively, those are pinkish tumor resected with clear arachnol but tumor interface, the ventrolateral aspect of the colon. So microscopy, the section showed a benign lab sheet tumor
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with a pythemic pattern of alternating high cellularity, but isn't 28, and low cellularity, that's at 20B regions. The highly cellular regions had interlacing lately cells with pythemic nuclei And
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we know these usually forms the varochal bodies. And the lowly cellular areas, their 20B areas, had thick, high-lamised blood vessels with loose, microcystic stroma, and
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scattered macrophages. So there were also some larger typical nuclei, and this was indicative of the ancient degenerative changes that usually show anomalies. So we made a diagnosis of a spinal
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schonoma, and we did in historical history. So S100 was strongly positive. Emma was negative. JFET was negative. And that K-67 index, we had a K-67
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index of 100.
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So on, yes, so I can, so on the microscopy, what you're seeing, this is, you can see a tumor and we can clearly see a biophasic pattern So
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this is where the black Casa is. We have this, that's the Antonio B area. You can see it's loosely cystic and not to cellular compared to
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the opposite section. Yes, that is the Antonio A. You can see the spindly cells
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showing a very highly cellular pattern. And then we can see areas of hemorrhage on the opposite, on the next year.
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a higher power, clear zone of
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hip origin
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and high-endized vessels. Since I'm not controlling the cassette, I can see this is a
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varucay body. We can see the fibrillary process and the spindly polysiding cells around it. So we can clearly see the varucay bodies or the varucay body in this particular photomycrograph. Again,
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very diagnostic of schwannoma. So this was some of
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the immunohistochemistry stains that we did, so you can see this was S100 and clearly you can see very diffuse positive pattern of S100
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staining. Again, this is very diagnostic of schwannoma.
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We did the Emma. Again, Emma was negative for this particular tumor,
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the GFP. Also, IHC was negative for this particular tumor, as you can see here. And then we have a very low K67 index, as you can see some areas of staining at 2. And again, we do not expect a
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high K67 index because of their very low malignant transformation. So, again, this is indicated with the diagnosis of it's been much known.
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Thank you, Dr. Berth. That was excellent.
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And now with that, this kind of illustrates the problem. That was a simple straightforward surgery. The main issue was presentation and timing of the patient. This is an image from when I
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graduated. from neurosurgery with Professor Wangonbe and with Professor Sunil Patel, who was an external examiner at
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the time. This was the workforce of neurosurgeons at the time. The next picture that we have is the last graduating class and you can see how many have grown. Since the since Professor Wangonbe
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started the program, we have graduated
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45 neurosurgeons. I think that's about since 2011 and we still keep growing. So at least we're targeting the healthcare workforce as of now. Thank you
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for your attention. Here's one. There's one. There's another.
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Okay. You have to convince them to join. It takes a long time. Okay. Just as long as you keep track. Yeah, we are keeping track. If you want to contact me, again, you can follow me on social
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media. This is my official email. This is my last book. Thank you for your attention, and I think we can start the discussion. Well, thank you very much, Michael. That was a very nice case,
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an excellent discussion. Would you comment on how you approach the surgical removal of the tumor?
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So it was a simple straightforward surgery. After doing the two laminectomies, the team found the tumor eccentric to the right It was covered by a layer of arachnoid tissue. It was large, pickish,
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not intraduro, no vasculature. More importantly, it was not contiguous with any of the nerve roots, which is what we were looking for. So to be very honest, the tumor delivered itself because of
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one dissection around the lesion itself, it popped out en masse. The problem is, yes, the problem is it's sad. It makes it sadder for the patient because this shouldn't have happened at all. If
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she was identified early, it shouldn't have reached this far. And for it to just be that diagnosis, that's what brings a learning point. Not everything has to be hard. Sometimes the changes are
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just very simple. I think that's why for some moment we picked this case, instead of us trying to show off any fancy cases or fancy equipment.
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Well, that's interesting that it just popped right out oftentimes with those large tumors, you have to do a central decompression in order to adequately get immobilized safely. Mm-hmm. So it also
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brings up another point and that is, you know, especially if these are emergent and middle of the night, whatever corticorna symptoms, you should be doing the simplest operation possible to get
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that patient on and off the OR table to do the adequate decompression. It's not the time to do a fancy multi-level instrumented fusion and all that other kind of stuff. Do you guys agree?
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Yes, absolutely I mean, I think if you're not. And that's certainly not the case here. If you're not needing to remove so much structure, so destabilize the spine, there's no reason to talk
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about
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doing a fusion. And just do a decompression, do an adequate exposure and remove the offending lesion.
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So was there, was there, was this a sporadic case? Was there any family history of spinal cord tumors or other tumors in this patient? No, she didn't have any family history of spinal cord tumors,
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which was interesting. Of note, I already said it before, we had
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a two level increase in the neuro grading, so she's doing better. I don't know if she'll get much more than that, but at least now she's able to ambulate With regards
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to the South Lannisteria, it's still present. obviously. And Bowel and Wether function, that's the next step. But that's going to be a long journey. But the main point of this is we should not
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get here. That's the one thing that I want all of the residents to know, et cetera, you should be telling everybody at any point when you see any neurologic deficit, any of the signs, as you told
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us quite rightly, it doesn't have to be a fool. As long as you get any one of the signs, send them immediately for an MRI, chase them up for an MRI, get the member of your staff to keep looking
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for the patients, calling the patients, because you can avoid a lot of things. I think that's the main learning point for us, but I'd like to leave. Yeah, I think you're absolutely right. And
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getting the ancillary personnel educated on this, you've got to get your nurses, your emergency room physicians, your hospitalists, I mean, everybody else who's seeing these people, your PCPs or
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your equivalent of that, they have to know what this is that It's not a total syndrome, it could be a partial.
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Like how often are you seeing spinal cord turns in your practice day at University of Nairobi? Oh, that's, they're every week. Every week is a spinal cord. Yeah, every week. Lots of eppentai
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momas, lots of
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eppentai momas, meningiomas, schwannomas, they're the usual ones. Every now and then, olecord, astrocytomas, and the ones that we're not sure what to do with them, especially if you think this
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one is late, some of the ones that we could show you would make you quite sad on what to do. Yeah, so I think that highlights the main issue that we have, even as we build the workforce, these
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are a lot more needed than the sedgeon themselves. And as I say, this is not just to you, it's even to the residents. They can affect a lot of change just by getting out of there and just talking
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to people saying, Hey, did you know that this exists? So I think that's the battle that we're facing, which is interesting
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So there's a question that's shared about.
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sacrificing the nerve. But I think you did mention that there was no apparent nerve involvement that you could just say. Yeah, we need to be very honest. As a team, two things are noted,
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especially from the notes, is this number one. We all expected it to be intradural extramodelery. So we got to it way before. Number two, it just popped off. There was no need for its section or
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anything, or any of those hard decisions That being said, we did have SSETs and MEPs available during the surgery. Yeah. So that was good. Were they absent in? No, there was a - there was 25
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improvement. Though it was quite low. I do not remember the numbers, but there was 25 improvement. I do remember that.
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So I'm curious, why did you think it was intradural? From the first image, from the presentation and the first image and the length of time, I didn't think it would be that. I thought the spinal
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cord compression, I didn't think it would be that. That's why I thought it would be intradural. Yeah, I'm just wondering if on the sagittal or coronal images you could have been discerned at the
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Dura was that it was only the lateral aspect of the Dura, just curious. I think it's the first mid sagittal image that I put up. It looked like it was intradural. It was ill-defined intradural I
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wasn't expecting a globoid eccentric lesion at all from the first image, the first T1 image, yeah.
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So are these - And you more with gadolinium might've helped with that differential. Yes, yes, yes, sorry.
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But you did have gadolinium, didn't you? Yes. Sorry, I just want to go ahead. No, we didn't have gadolinium, which was tracing the images
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the Daikom images, the Daikom images were split. They don't save everything on the hard disk. Oh, yes, yes, yes. Yes. We did not need to sacrifice the nerve for Sajima. That's the issue. So
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that's the
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good. Or whenever you're saying, we didn't find the root nerve, we have to be honest. Sometimes you don't find, so I didn't find any source at all. Yeah.
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And another point I wanna reiterate is the importance of doing the physical examination in the context of Dr. Epstein's lecture and in this presentation, in that
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the manifestations described can be attributable to a lesion in the thoracic spine. So you talk about bilateral low extremity weakness, you've lost a bladder and bowel functioning in sensory changes.
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So it's the importance of the examination discerning whether they're upper motor neuron signs. I wish there was a medical student or resident, I could ask what some of the upper motor neuron signs
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would be, and then of course, doing the appropriate sensory examination to determine where the level is with. Is there a thoracic level? Is there a saddle anesthesia? So just the importance of
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doing the basics, taking the history and doing the good neurologic examination Is there somebody, Dr. Maguha, that you can ask about some training regarding upper motor neuron signs that they
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would look for? Yeah, and they better make me look good. Is Dr. Alim, Dr. Ridwan, Iber him, I think they're up to the task. He's smart. He's staying with me. Dr. Iber him, he can't. Dr.
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Iber, he'd be a
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good one. He's one of the few residents who will be going back to Somalia. They are way fewer than us I think it's less than five or so. So, he'll have bigger problems than us. Yeah. Okay,
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while we're waiting for one of them to respond, Dr. Morgan, welcome Jay. Dr. Morgan has his hand up. Go ahead, Jay. Oh, Dr. Gavenji, who can answer that
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question? Sorry, yes. I just, I sent you a text as try it, but I just had a case,
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Michael McGaud, that occurred over 23 hours Patient presented with weakness in the lower extremities,
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had increasing bone bladder, and we got an MRI, and it was very difficult to tell what was going on, but it looked like there was an intra-dural lesion and operated on it immediately. There was
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also blood at the base of the
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dura,
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and it ended up being a hemorrhagic pentamoma, which I haven't seen before,
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I ended up taking that out at about three o'clock in the morning. And, um, but the patient got just progressively worse while we were waiting for the MRI scan, which was quite interesting. I
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said, I'm going to go into the tumor. I'm sorry. Well, patient hemorrhaged into the tumor, which is what we said. Patient hemorrhaged into the tumor. Yeah. So was it, uh, was it an exophilic
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tumor, uh, with. It was interdural. Oh, it's interdural. Oh, okay. Okay. Okay Yeah, interdural. Exophilic from the conus. Yeah. Yes.
27:57
Well, actually it wasn't on the conus. It was, it was attached to the phylum. Um, it was able to just be sick. But it was at the level of the conus. So I see that,
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but, um, so the typical location for the mix of papillary appendamoma, yes, but it was hemorrhagic. It was hemorrhagic and he had no symptoms prior to that. It occurred all with it, uh, 23
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hours and he was transferred from another hospital. that's why it took so long.
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Did you say it involved in filing? It did. It did. And CSF was bloody as soon as you opened up? No, this CSF was fairly clear. Did you save some of
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it for cytology? No, not to see it. We got a full resection at tumor. And it was very large because I didn't know exactly. I thought it was an AVM initially when I opened because it was under
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pressure. Because it was hemorrhagic. Right. But as I opened the Dura, it
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just popped out. So, Wow. Yeah. Very interesting. Thanks. Thanks, Jay.
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Yeah, sometimes those lesions are stuck to a lot of nerve roots. And then you can do it as you can. And then you usually give some kind of vocal radiation or stereotactic radiation to to the region,
29:19
right? Right, but it was not stuck to anything. We'll get full cranial spinal axis to the brain or cervical spine yet, but we'll look there. We did the thoracic spine. And - Where are you
29:32
located? In Reno, Reno, Nevada. Okay. Yeah, so. Yeah, we just - This is part of the last week.
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Well, I think Nancy, this is a great demonstration of recognizing
29:52
the presentation and intervening in a timely fashion As Dr. Morgan said, he was in the operating room at three o'clock in the morning, so he wasn't waiting until the light of day. Exactly. One of
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the main issues we have with practicing here is sometimes you get these situations which are out of the textbook, and you know you're forced to do something because it shouldn't be a three month
30:09
emergency. So that's one of the things to highlight. If you're looking forward, anybody looking about studies to do, follow up on any of these patients, we have them. So, and no one writes do
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with them. So we have to keep deciding where to go. So especially follow up, recover recovery, etc. Anything else that could add spinal cord stimulation, all of these things, we have these
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patients and I think we should showcase and highlight that that's one of the differences in practicing locally here because we know we're supposed to do that. If I'm on call in a private hospital,
30:39
I'll do exactly what Dr. Morgan did. If I'm in the public hospital, we moved really fast after three months.
30:49
You see the issue that we have, but we don't get so this is why the form of SNI digital is important. You get to see difficulties we have in management and thank you for the opportunity. Thank you.
31:04
Did we get a resident or student to make a comment? There is
31:12
a there is Samuel Davengy who's there. I think they're all scared.
31:17
Okay, well, I'll, I'll, I will, I will take it on. So if we're, if we're trying to differentiate up on what a neuron manifestation signs, we're, we're going to be looking for, for
31:29
hyperreflexia, we're going to be looking for, across that ductor reflex, I often use that, I'm looking for a babenci response, an extensive plantar response. And of course, looking for,
31:45
looking for the appropriate sensory level. Any, any other, any other additions?
31:52
I can, I can say what I use to teach practically. It's going to sound macabre, but most residents remember. So distinguishing upper and lower motor neuron lesions, always imagine there's the
32:03
teacher and there's the students. So if you go to a kindergarten and you get rid of all of the students, that's a law of motor neuron lesion. Nothing can happen. Everything is gone. And then And
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then the converse is true. So if you go to the primary school and you get rid of all of the teachers, everybody's going to run wild. The students will be up and arms. They'll be everywhere.
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Everything will be increased up, up, up. So that's the real, you'll tell them all the time. Great, great, great. They'll be hyper-reflexated. They'll have increased tone. Excellent. That's
32:36
a good way to do that. A big scale, up going, everything will be up, up, up, up, if you get rid of the teaching. Excellent, excellent. Excellent, excellent. You know, the case that was
32:44
just presented and, you know, your T12L1 lesion, how many lesions high up are missed on MRI scans and how many of us forget that there is a thoracic spine above the lumbar spine, especially if the
32:57
lumbar study is not diagnostic. I mean, I saw a patient, you know, a few weeks ago and, you know, the neurologist had sent the patient and patient had a unilateral foot drop but had been there
33:08
for a bit. And I lived at the MR and I called him back and I said This, MR does not explain this deficit.
33:13
You know, you've got to think of ALS or CIDP. And by the way, where's the thoracic study here? I'm still, you know,
33:31
I have to get back to him and find out what he thought. But, you know, it's like, look up is basic. No, absolutely, absolutely. Absolutely, and don't believe what the radiologist or
33:32
neuro-radiologist has read or over interpreted into it 'cause especially if it doesn't fit.
33:40
Yeah, that's such a great point I certainly have seen people who have lumbar degenerative disc disease and they've been treated with the assumption that what's going on with respect to their pain is
33:54
from the lumbar degenerative disc disease and you do an examination and they're myelopathic. And so, and they've never have had the thoracic spine evaluated. Yeah, yep. Excellent point. Oh, any
34:08
other questions or comments? Yes, I just could. Professor Epstein.
34:14
give us some comments on coder equina syndrome and conas medullary syndrome. Well, I mean, like we've been discussing, if it's a conas syndrome, you know, you may have, because you're getting
34:27
the distal aspect of the cord, you may get the upper motor neuron findings and not just the lower motor neuron findings that you're going to see with the typical quadraguina syndrome. I think that's
34:38
the biggest difference. You can get proximal weakness in both cases. You can get sensory findings, but the sensory deficit with the conist lesion is going to be a few levels above the lumbar spine.
34:45
You may be getting T10, T11, T12, L1, depending upon what you're looking at, whereas usually, you know, quadraguina, you're seeing L2 distally. Am I right or wrong in that, Estrada? Well,
35:03
I think you're right, Nancy. I would also say with the conic syndrome, you might be more prone to have evolution of bladder and bowel disturbances, as opposed to the motor changes that typically
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would sometimes herald the Cote Aquinas syndrome.
35:29
Any other comments or questions?
35:33
Well, this has been fantastic. Two excellent presentations were from two great experts, different parts of the globe, and I appreciate all of the participants being here, and I appreciate Dr.
35:50
Morgan. He may have had to go back to check up on his patient, but but just presenting, give him mention of that case that complements this whole discussion. Let's go ahead. Oh, okay. I didn't
36:02
see. All right. Yeah, thank you so much, Jay And
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Michael, excellent. We've we've we've we've valued the contribution from the group in Kenya and look forward to further participation. And Nancy, well, you're a part of SI digital, so we'll,
36:24
I'm sure we'll always, we'll see you again and look forward to your participation. I'd be happy to, anytime. Thank you, thank you all so much. On behalf of Jim Osmond, who put this all together
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and sponsors this, I wanna thank you all and I'm sure he'll be very pleased with the participation that we had today. So we'll sign off, the next one as always will be the first Sunday of January
36:57
and we'll be getting out the announcement and putting the program together within the next week or two. So thank you all very much and enjoy the rest of the day or evening. And thank you, Estrada,
37:10
and thank you, Michael. Thank you both for the It was fantastic. Thanks so much. Thank you. Okay, bye bye. We hope you enjoyed this presentation.
37:22
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