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SNI Digital, Innovations in Learning, in association with the host neurosurgery lab in Baghdad, Iraq, are pleased to present the 21st SNI
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in SNI Digital, Baghdad Neurosurgery online meeting held on January 20, 2024 The meeting originator and
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coordinator is Samir Hose of
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the Universities of Baghdad and Cincinnati.
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The theme of this meeting is on spine diseases, complex spine, spinal cord, and nerve root diseases, successful management strategies outside high resource environments. How we do it?
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The moderator and discussant for this meeting is Nancy Epstein. who's the clinical professor of neurologic surgery at the School of Medicine and State University of New York, at Stony Brook in New
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York,
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and also the editor-in-chief of Surgical Neurology International. The speaker is Dr. Ali Adnan Dalaji,
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who's the assistant professor in neurosurgery at the El-Kindi College of Medicine at the University of Baghdad in Baghdad, Iraq.
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He will talk about complex spines, spinal cord and nerve root diseases in a limited resource environment, and will present two outstanding cases done with, in our opinion, superb thinking by about
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very compassionate and skilled neurosurgeon clinician.
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Case one is a patient with multiple myeloma, We had a bone marrow transplantation in another center and on outside the country. And an occurrence, reoccurrence of the disease in a thoracic spine
2:09
with instability at creative treatments. And after many months, had a 12th nerve palsy that were symptomatic with no further progression of the disease. He'll talk about what he did and how he did
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this challenging case
2:30
In his second case, he'll talk about a patient with a symptomatic lower clival mass that led to the transoral removal of a lesion with a surprise diagnosis, followed by a cervical occipital fusion
2:46
in a challenging environment. You'll find out what he did, how he did it, and why. And in this example, there's a message for all neurosurgeons, physicians, on providing the best one can do for
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the patient wherever you are.
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Thank you for inviting me to this amazing meeting. My honor to be between you, to
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present my cases,
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and share my symbol, let's say my symbolic experience, the spying surgery, as Dr. Haszade, I'm as the professor neurosurgeon from McKinsey Medical College, University of Baghdad, and
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work as a specialist in neurosurgeon in neurosurgical teaching hospital in Baghdad.
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Our objects of my presentation to focus on complex spine surgery and the limitations that facing us and us ourselves. fine surgeon and ERAC, we will explain that through the presentation of two
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cases.
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My first case is
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55 years old female with the history of hypertension at the SIM card disease on regular treatment diagnosis as a case of multiple melanoma at the end of 2019
4:27
The first diagnosis as multiple melanoma by
4:32
appearance of a sternal mass, which is operated by the cardiovascular surgeon and the histobophology reveal, sorry, this is a case of multiple melanoma The patient received regular chemotherapy by
4:54
follow-up the oncologist and did the bone marrow transplantation in
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Turkey at 2020.
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And
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during that period, the patient to pre from symptom and regular follow-up with the hair oncologist at the two of July, 2022,
5:23
the patient developed severe back pain. And the MRI revealed there is a mass in
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L1. When I, this is the mass, as you see in
5:42
the MRI in the L1 mass, I advise them to do surgery, fusion surgery, with the decompression of the mass but the family refused to do surgery,
5:58
They decide to receive a dose of radiotherapy or radiation for the bag to relieve the pain and diffuse surgery. At that time, the patient just having severe back pain, there is no weakness. After
6:14
three weeks of the receiving radiotherapy, the patient develops
6:23
lower limb weakness of around the grade two to three, especially on the left side. Then come back to
6:34
me and advise them again to do the surgery. This is the CT scan of the same patient with sagittal and coronal views, as you can see This is the
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mass at
6:53
the alwandis tractive region involving the body of alwandis. and look for
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the bone density of the spine. In the patient have
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osteoporosis or element of osteoporosis because of the, it is used for at least two years, heavy dose of
7:20
steroid of dexamethasone at each week
7:22
My plan was to do fusion
7:29
from doors or lumbar fusion with posterior approach to the body, to do carbactam with insertion of
7:43
pyromish or titanium cage. But
7:48
the patients didn't have the price The price to pay a lot of
7:57
A lot of money for instrumentation, that is why we omit the pyramish and insist to do
8:09
the dorzo lambar fusion. We use the
8:14
cannulated cicru, because the bodies of the adjacent level are osteoporotic, but we have the cannulated cicru, but the problem, we don't have the special injector or feeler of the ponciment to the
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cannulated cicru. That is why we use a modified method by using a tangoge syringe with the needle of the blood in the fusion set, and it's reducing the ponciment inside the.
8:50
inside the.
8:57
this is the improper of the picture of diffusion, this is
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small amount of the obtained here by
9:15
I'm impressed and do
9:19
for coming from the posterior, posteriorly,
9:25
L1 with putting a small from me, submit, post
9:34
it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it,
9:34
it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it,
9:34
it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it, it
9:48
Dr. Ali, we lost you. Can you share again this screen and unmute yourself?
9:58
You are muted now
10:03
And can you share this clean again, please?
10:09
I don't know.
10:14
The thoracolumbar fusion that you're doing with the cannulated screws, you're talking about injecting polymethylmethacrylate, PMMA
10:22
into the screws, I assume
10:30
Dr. Ali, you are still muted
10:40
Now, my sound. Yes. Yes. Yes, sir. Yes, sir.
10:47
I use the, the spinal metal acrylic, which is also, as you know, it is have a low viscosity, and other, and like
11:00
the standard bony cement, which is that is yours in the corner of last year on an orthopedic surgery That is of low viscosity
11:12
to be injected in the cannulated, and the cannulated screw, but actually we don't have the specific set or the injector That can be filled under the
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cement correctly, and come through the screw to the bed. So you're doing it free hand, basically. Correct?
11:39
And what about the inter-body injection? Are you using a piece ofiliac autograph
11:45
instead of an inter-body device? What are you putting in? I would actually, I would
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the bone cement also. Inside the body, after I remove
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the soft part of the mass and do the partial core-pactomical for the L1, for the L1,
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I put, as you can see, this is a pony cement, a pony cement for
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the patient. Did you consider taking a piece ofiliac autographed or bone or allograft bone or getting some kind of bone to put in there in addition to the cement itself? Yeah, my plan was to
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put this autograph
12:43
in
12:48
a pyramish or titanium mesh, I inserted there. But we don't have and the patient cannot pay this cement and fear to put the autograph alone and the all the spine are unstable. That is why I fear
13:01
from the displacement of the graft, especially all of these area are diseased And
13:10
you walk by the tumor. Actually, I fear from the displacement of the sludgement of the autograph from its place.
13:23
Right. When you put in the cannulated screws, did you get from any of those vertebral bodies, did you get a bone biopsy or bone sample to document whether they two were involved It was not just
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osteoporosis. Actually, I don't take the biopsy from these levels, but from the feeling the segment of the
13:53
pond, there is no,
13:57
I operate many cases of multiple myeloma, when you introduce a body finder or the starter, or
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the starter to the, especially when you reach
14:14
the body, will some look like a bone moral material comes from the hold, which means the body or the vertebra involved by the
14:31
multiple myeloma Actually, we don't have a processing section biopsy. That is why we, we do want, and the, MRI picture and our experience to judge what whatever this patient is, or this vertebra
14:47
involved or not.
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And I have a question, when you did the bone marrow transplant, how much did you know about any disease, any place other than the sternum
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at that point? Actually, it is not my patient at that time, but the family said to me,
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after doing
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removal of the mother from the sternum and received chemotherapy on, her oncologist advised them to go to Turkey to do a bone marrow transplantation, but this transplantation is failed because the
15:34
patient after one. One and half year are away. or around this period. The villa bricurrence of the disease, meaning this is the transible heart, a failure.
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Okay. Okay.
15:51
Our journey with this patient is not ended at this level.
15:57
After
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three to four days, the patient develop
16:07
the patient start to move her lower limb and the grade ranging from the two to three to four plus at the end of our time of removing the suturing, the patient can start
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to walk with full recovery of the movement. As well, there is a dramatic response. to pain, and the
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pain is only at the side of the surgery, but not so severe, as a breath about activity. This is a
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3D reconstruction, as you can see in
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this view, this is the CT after a 3 month of surgery The patient starts with the normal walking, and to come to the hospital without wheelchairing, and this is the
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concentrate, with the starting of the fusion at this level, and this is the CT, because I don't have the previous picture of the patient This is the CT scan of the thoracic cage showing the
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previous mass and the sternum.
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I put this picture here, and this is
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going to be considered. After that, it is about less than one year at the 16th of May, 2023.
17:53
Patient developed the space here, and severe headache, especially at night. We start our new work up Where during examination, actually the patient don't have a
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true dyspiesia, but have a mild difficulty in speaking in the speech. During the neurological assessment, all the neurological assessment are normal apart from there is a deviation of the mouth to
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the right side, which is mean there is. and
18:41
hypoglossal nerve balsi. And there is no pability in it. I mean, I think about the skull metastasis because the patient has a bearing headache without back pain. This is
18:56
the, I mean, there is no sign of praised intracranial pressure. This is the MRI of this patient. Actually, I don't have the many section of the MRI, but the
19:12
radiologist said in our road in this report, there is a small bone edition near the performing magnum.
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There is a two lesion, sorry, the
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first of it near the performing magnum, and the second one near the frontal I have the picture of the. of the frontal, this is cause, the severe headache of the patient. This is the elliptical
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lesion of this of the skull. And the another one in the base of the skull, that is why patient develop hyperglossum nerve palsy. And during the examination after one month, during examination of
19:56
the patient, the patient have a floating of the,
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this is the MRI of the cervical.
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All things are good. And this is the
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Lambo sacrum spine, also the good. But I send her to do epsilon for the back. Although the patient don't have a back pain and there is no weakness. But when I examine my previous scar or the
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previous wound, that is a floating of the of the roles. of you as you can see here. This is mean, the net are
20:42
outside the
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road, with the displacement of the road. This complication, because my cannulated screw set is an all set first and the second,
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we don't have the final tighter of the net. That is why we use the same screw drive to lock the
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screw. We did it for here, and a revision surgery, and put the screws, sorry, I put the net on its side, and the patient get well,
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receiving after doing the revision surgery and radiotherapy, not for the spine, radiotherapy, for the new lesion
21:45
of the scalp, patients get well and grew in the headache, but still having deviation of the mouth. From that period till now, in addition to free of symptom, relating to her previous spine
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surgeon.
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It's the deviation of the tongue? Yes, sorry, sorry, sorry, the deviation of the tongue because of the
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right hypoglossal nerve involvement of the second mass that involved the base of its scalp
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Is the patient getting any immunotherapy, chemotherapy, any other follow-ups? Yeah, yeah, it is on, yes, and during this long journey, the patient has stopped the chemotherapy only two weeks
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of surgeon, that is all. After we removed the future, I sent a referrer back to her oncologist and continue on the same regime
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of the chemotherapy
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and use of dexamethasone and the
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other
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adjuvant therapy. Yeah. The main follow-up of this patient from her oncologist that about one to two visits per month to her oncologist, They see the.
23:33
referred her to me and about every three to four months when the Asian developed complication related to the CNS.
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Okay, let us go to the to the second case is also female of years old with the common history of cervical pain at the second
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of October
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2023 become having a severe cervical cervical pain at the
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at the 10 of October as family said
24:17
patient developed an ability to hold her head at the
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20th October of the 20023 patient unable to stand and work At this period, I don't see the patient. I took this information from the family. At
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that time, patients do survive. So MRI and having SC2 masks. Also, I don't have the picture of this, or MRI or radiology of this picture.
24:58
Also, the patient has that period This
25:02
is the due to investigation in addition to CT and MRI of
25:13
the cervical, do petisca,
25:18
and serum, protein-eliquetrophoresis. Because initially, a
25:24
time of that period when see a medical advice from the ancologist and appeared there is a. amass in the G2, they think about the metastases or multiple myeloma. But
25:40
the back scan is normal apart from - there is a lesion of the C2, the same result of a marion ceti. And protein, elicatrophoresis - actually, it is not as specific. There is no result, meaning
25:59
the patient may they didn't have a multiple minor one. After I received, I received the patient and the beginning of the November, of the previous year. I start a new workup for the
26:17
patient. I did a new MRI and C2 scan. As you can see, this is the lesion of the C2 body with partial
26:29
involvement of the dance. This is a T1 sagittal amoroid and this is the T2 sagittal amoroid. Look for this
26:43
with gato.
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This partially or our weakly enhanced vision mainly involves the body with minimal
26:57
pressure
26:60
of the of the court. At that time the patient as I said unable to hold her head because of the severity of the pain and unable to walk with upper limb and lower limb about a great pre-weakness.
27:26
This is a nice picture of the CT scan of this patient as you can see in this this is a coronal of you,
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this is a attractive lesion or aqueous pencil, sorry, aqueous pencil,
27:40
bone lesion involving the C2 body in this sagittal, this is the sagittal, and this is the coronal, this is the coronal view, and this is the pre-degree construction of the spine
27:57
At this point, my plan was to do a transoral approach to address the mass and decompress the mass and taking biopsy because the previous investigation was not conclusive about the diagnosis of the
28:19
patient and the same time after doing the transoral approach. I will do, this is my plan.
28:30
to do cranial cervical fusion for this patient. That is why I prepared this patient for the surgery.
28:41
I do for her, as you know, in the cranial cervical of the fusion. And it is important to do the CT and geography for the blood vessel,
28:59
posteriorly as this is the posterior loop, to see the real course of the vertebral artery in relation to the cranial, so C1, C2, and C3, and C3 complex. And to see any variation of this course,
29:16
because it's dangerous during this action to prevent injury to the
29:26
vertebral artery.
29:29
And this is the lateral view, from this view, I address the anterior part, also because I plan, I plan to do the transoral approach for this patient. And there is no, as you can see, there is
29:48
no unapparent force of the
29:53
vertebral artery. This is make us more quiet
29:58
to do the surgery, because we don't have, we have only CR, we don't have an navigator, a cooperative navigator, to localize the deletion.
30:14
With the contrast scan that you had, or the CTA, didn't you see a blush in that C2 lesion, Embolize it, or think about doing something like that.
30:29
Actually, in our hospital, we don't have an embolization catarization, or when we suspect a vascular lesion, we don't have. We have only two, I think, two centers, it's a private center for
30:52
embolization And this, the surgery, in governmental hospital, and the patient is very poor. They can't pay even the price of the screws.
31:12
I think about the embolization very operatively, but actually, I didn't talk this
31:21
subject to, I don't, sorry, I didn't discuss this subject with the family.
31:28
Because I know, when I discuss
31:35
the price of the cranoservical fusion for the family, they say to me, which is about an Iraq, a cranoservical plate and secreuse, sorry, occipital plate and the cranoservical
31:51
fusion, it is ranging from 2, 000 to 2, 050 US dollars. The patient, the
32:00
family, said to me, we don't have even 300 dollars.
32:07
Please make your connections to solve our problem. That is why I don't talk with them about the characterization because at that time, I think about how can I make these screws available?
32:26
to prove that available.
32:29
Okay, okay,
32:32
that is why we do this as the city
32:38
NGO. I call my colleagues because my hospital, we don't have an ENT surgeon. I call my colleague in other hospital to do with me and transoral approach for the C1 is an ENT surgeon,
32:46
but not familial to use
32:54
the microscope.
33:04
That is why we choose the endoscopic transoral approach because it's an ENT surgeon and familial with the use of the endoscopy.
33:17
Again, we don't have this special instrument like the pigment retractor, the corongeror retractor, That is why we use.
33:30
the ordinary tractor of the tonsillectrum. And we use for the foreign job attractor. I use the castor attractor of the of the ACDF.
33:43
With the smooth blades. Yeah, yeah. I use the blade of the longest one The
33:53
longest one blade for this patient.
33:58
This is an interoperative picture. We start to this is in the tractor tube. This is the beginning of
34:09
the end of the arm The the the the the bosteror for one zero and we start to dissect the
34:24
ractoscolite muscle.
34:27
And after drilling, as you can see, this is a very bloody field. During intercourse and cooperative
34:39
finding, I'll a lot of think about this is a case of a neurospon pole cyst, because it's not a texture of the multiple myeloma and even not a texture of metastasis, bleeding from anywhere of the
34:58
body.
35:00
As you can see in this mini video, this is
35:05
after doing the drawing of the sewer, the bleeding is very copious, from the
35:14
inner side of the of the of the situ.
35:21
We do
35:23
a little bit more than a partial, for bactomy of the C2. Beside, we
35:32
remove the dense and the post C1 arch. This is at the
35:39
end of the first step of the surgery. I mean the endoscopic transoral. This is the blade of the Caspar sky of the ACDF. Make it as a pharyngeal retractor This is after removal of the part. This is
35:59
part of posterior longitudinal ligament. We exposed here and we leave the partial of the bone laterally. After we go ahead to the second part of the surgeon
36:22
During the second part of the show, we open the patient in the center.
36:29
under trans posterior approach. We don't, as I mentioned to you previously, we don't have the
36:38
ideal link to crew for this level. We only have the long, as you know, and in sub-exial lateral mass, we need, the
36:53
crew link is ranging from the 12 to 16 millimeter. The available, in our hospital, we have all the
37:03
crew of lateral mass, but all of them are too long.
37:11
And it is ranging from the 25 to
37:15
28 millimeter, which is too long to introduce, and the
37:24
lateral mass of the sub-exial. I use the road cutter and cut, as you can see in this view, I cut
37:33
the long road to make them shortly after I measure
37:40
the depth by the - So they're no longer self-tapping screws, so you have to tap it before you put the screws in, correct? Yeah, yeah, yeah. What about the occipital screws? Because that's even
37:52
more tricky
37:55
Some occipital screws. Some occipital screws. Actually, we have the link, the range, from the 8 to 10 million. I use the available screw.
38:13
Some of the screws
38:18
go out outside the skull, but the patient tool, there is no - CSF leakage. There
38:27
is no bleeding. That is why we put this the cranio-survivcal effusion. This is our obstacle because we don't have the ideal length of the lateral mass. We
38:42
strictly call up this patient during the first week because the patient on MG
38:50
was of the pharyngeal wound and the monitor patient
38:56
may may develop at any time, pharyngeal swelling and the trider and may need the tracheostomy. Are you also worried here? I'm looking at your lateral view. You've kept the posterior aspect of C1,
39:14
the arch. Are you worried that that's going to prevent the cord from moving dorcely within the dural sac? And that might be a site
39:24
I talk partially the interior arts of the C1, you mean? Now the posterior arts of C1, I see still intact. No, no,
39:41
I don't take it. I don't do laminarctomy of such patients
39:46
because
39:49
in the CT and MRI, and MRI, the
39:56
C2, posterior part of the C2, that is not involved. After that,
40:02
I take a multiple biopsy from the laminar and
40:09
the
40:16
laminar is very sethron, look to be not diseased That is why I decided to leave it at its end. posture
40:25
to make the fusion better, okay, okay,
40:33
after one week, we remove the energy and the patient to start to walking in the second day. The
40:41
patient only have a small or sample, sorry, sample, survive campaign at time of cesare jury. The history of apology, as you see, in your neurosmal ponsist, there is no malignancy. Actually, I
41:00
say
41:04
to the patient, I advise them
41:08
to go to the oncologist, although there is, as you know, the neurosmal processes are a been a kind of vision, but many articles say that some doses of radiotherapy may
41:27
prevent recurrence or stop the progression and decrease the vascularity. That is why I refer and my patient to the oncologist to receive some doses that are ranked by
41:42
radiotherapist to prevent progression of the disease. So now the patient well, start walking with very minimal cervical pain.
41:57
Do you have a post-operative MRI scan? Shall now know because I
42:07
operate this
42:13
patient at the end of November and after taking the biopsy, the patient to send to the oncologist Mm.
42:24
I say to them, I will repeat the MRI after three months. No, okay. Yeah.
42:33
I will inform you of the time permit for me to send the new MRI patient on a CT
42:46
scan My message in the
42:51
spine surgery, the
42:54
limitation of the instrumentation are a lot. You can modify your instrumentation to help your patient, but you should be in the safe side Always be safe, always be safe during modifying your
43:14
instrumentation, and the second message.
43:21
Sorry, complex.
43:28
surgery always the patient having a long journey that is why you should be meticulous to follow you up the patient and the patient may develop complications at any time and many of the complications
43:45
may not relate to the to the site of the surgery itself of the at the first case the complication or the new development of the disease related to the serum premium and thank
44:07
you for your kind listening and there is an equation I'm ready thank you for kindly so
44:10
thank you thank you Dr. Ali thank you for this nice presentation this nice those nice cases I just want to add something before asking the from the professors, first, the neurosurgical
44:30
center, it's called the neurosurgery teaching hospital, which is in the center of Baghdad, it's the capital of Iraq, and it's the first and the main neurosurgery
44:41
center all over the country and the main center for trauma. This center has a specific setting, it's a tertiary center for neurosurgery, because this is related to what Dr. Ali described about
44:54
there is no ENT surgeon, and this seems odd, but our main center is a tertiary center for neurosurgery, contained only neurosurgery service, basically like 90, and 10 maybe neurology, and that's
45:11
it. And it's a separated hospital, separated location. So it's very nice for neurosurgery, it's all neurosurgery hospital, but at the same time. it's not easy to connect with other specialities.
45:24
That's a peculiar about this location as described by Dr. Ali. And the second point is, as far as my experience, umbilization of this location is need some
45:39
experience. And I don't think this experience available yet. And I'm not because it's near the skull base and if done randomly, like pre-operative or umbilization, it can cause easily our training
45:52
of policy or major complication. And at the same time, estimated cost will be45, 000, will be like double or triple
45:59
the size of screws, for example, just to make those more clear. And yeah, the mic is yours, Professor Nancy. I mean, I think that these are some very unique, very complicated cases that we're
46:18
operated on with a. finesse and obviously great care and studies were obtained preoperatively to adequately plan what the postoperative status would be.
46:32
The outcomes seem to have been good for the cases that were presented. We all know that there are cases that any of us have ever had that may not have come out as well. I think it emphasizes that
46:49
patient work up preoperatively is critical. We've spoken about MR, we've spoken about x-rays especially I think cervical and lumbar. I think most fine cases at least here in the states a lot of
47:02
them deserve to have CAT scans although many of our surgeons don't get the CAT scans and then they get some real surprises as a result of not having done those CAT scans specifically in the neck you
47:14
may end up with cervical ossification of the posterior longitudinal ligament. and a quadriplegic patient because you went to do an ACDF that you thought was simple, and the whole thing was ossified
47:25
before you knew it, you were in the middle of the spinal cord.
47:31
Resource utilization is a problem. Whether or not patients have the finances to do the studies that you need. It's an interesting question because I think in the States sometimes, the patients who
47:46
can't afford it may be getting the safer operations with less instrumentation and fewer complications because they're getting a simpler operation. Whereas in other instances, if there's more money
48:00
to be gained by putting in all kinds of instrumentation, at least in the States, more money is gained by the hospital, more money is gained by the surgeon. So it's not always what is best for the
48:13
patient where I think all of our interests should be focused on what does the patient need? What is best for that individual patient? And I think that that's what has been discussed today and very
48:27
nicely addressed.
48:30
Jim, any thoughts about that? Ollie, yes, thanks Nancy. Ollie, that is just an outstanding job. I agree totally with Nancy. You've used all the resources at your disposal very intelligently
48:46
You've been very safe and very cautious, very thoughtful.
48:54
That's outstanding anywhere in the world. They handle an extremely complicated problem. The way you did it, you did it. Just a terrific job.
49:07
How do you, this is another example of both of these people, superior, superior.
49:16
Doctors and physicians in Iraq where people wouldn't think that this would happen. These are just superb results, superb thinking.
49:28
Your influence is still shown. Ollie, that's just a terrific job. Thank you, thank you, thank you, my brother.
49:41
So, Samara, where do we go from here? Yeah, we can have a few comments and
49:49
maybe two comments. And then either if you want to share some slides or
49:59
we can go just to the Q and A at the end of the, of any student or a center surgeon I think we should do some Q and A and Samara, I think the other thing to think about is, you know, do we have
50:14
follow-up sessions every month, every few months, where cases can be presented even before they're done to get different opinions as to what recommendations might be. And that's how some of these
50:27
fine conferences could be used. I mean, what Ali, Dr. Ali, what do you think? How could you use a conference like this? Yes, yes, it's very helpful. to see your advice and
50:44
my opinion to make a follow-up meeting for this to give you a feedback of these cases within new series of investigation like that
51:01
is kind of amoroid to see what happened for this patient during follow-up and hearing from you The advice is what to do
51:13
well your
51:15
accomplishment and that of the asset really fill my heart it's really tremendous and I remember that the saying said that leaps in our time or in the past were just steps what steps now your steps are
51:32
leaps so your progress is so fast so wonderful so matching the international standards. makes us proud of your achievements, you and the asset and your colleagues, including Samberg, of course.
51:46
Thank you, thank you, sir. You and Dr. Sadh, and Dr. Sameer, put the line of us, and we follow these lines
51:59
and make the work upgrading. This is growing your lives. What's your effort for life? It's a tremendous effort and achievements really. Thank you, sir. Thank you, sir.
52:14
Some here, what are your feelings? I mean, I know you're a vascular and an endovascularist and all of that kind of stuff, but just in terms of comments of, you know, where neurosurgery is in
52:28
Iraq, it's interesting to me that you have a hospital that's 90 neurosurgery, but neurosurgery does need not only neurologists, but other specialists around because sometimes other complications
52:41
arise. What am I referring to? You do an instrumented lumbar procedure. I don't know if you have X-lips, extreme lateral interbody fusions, but those are procedures in the states or even just a
52:56
T-LIF or a pedicle screw in the lumbar spine. If you have a perforation of aniliac vessel, who's going to help you repair this, do you just have your neurosurgical colleagues who don't know how to
53:08
repair
53:11
it? And we. We usually use a good friend who is, for example, vascular or thoracic if you like if you need additional specialty. So you use your personal connections to have a friend spend the
53:29
full day for free in a governmental hospital just in case you need them. This is usually used always in the cervical or trans-oral approach or trans-phenoidal sometimes with the initial experiences.
53:44
Yeah, with the initial experiences for skull base they use TMT a lot then with the experience they don't need them. So it depends even like even in urgent polytroma cases. So we need to do with the
53:57
chest tissue first and then we start consulting cardiovascular centers. So it's weird but at the same time I think it's very rare around the world to have a center with a 24-hour emergency. on
54:13
linear surgery. So for resident, I don't think this experience is comparable to spend the day in the emergency department receiving on linear surgical cases. So it's very different from other
54:28
emergencies, yeah. And you can operate the extra-dural hematoma from like door to OR
54:35
in like 10 minutes from it's the same corridor for emergency in a CT scan than OR. So the setting is like for real emergencies more. And yeah, it's interesting. But yeah, as you said, the
54:51
connection with the other specialty is definitely a limitation. Yes, Sam, but if you take the main teaching hospital for the medical school, what's the neurosurgical department there is in a major
55:06
hospital where all the specialties are there So the part is neurosurgical centers, pure neurosurgical centers. there is the center which is the middle of a teaching hospital where all the
55:16
specialties are available, you can't hold anyone if there is any emergency there during your surgery. Yeah. One question for Dr. Ali, when you did the anterior transoral approach, what was the
55:30
time period between doing the anterior and the posterior surgery and is there a part of you that would have liked to have obtained an MRI scan to make sure you did not have a significant anterior
55:44
hematoma before you turn the patient over to do the posterior surgery. Actually, we we didn't
55:53
have this facility. I do the surgery started about 10 am. at morning. The end of
56:05
the
56:08
transoral surgery is about as I remember. one and half pm. Then I take, I talk echestrate to see the the pharynx and the what the there is no swelling to proceed to the second procedure. Actually,
56:31
at the same time,
56:35
when we see there is no swelling and the the patient are vital stable and we wait at least for half an hour before occlusion of the
56:48
of the of the of the of the mucosa and the and the rectus cholite and the seed I and I say to them to the anesthetist to raise the blood pressure that the body pressure a little bit more than the
57:06
normal initial blood the pressure when the patient before induction. that I, also I bought a surgical and some of bone wax and wait, wait at least for half an hour because I don't this facility to
57:25
go with the patient with the tube to the armoire and go back to
57:33
the surgery. When I make sure at least by the neck die, there is no obvious ability to think we closed the muscle and the closed the mucosa. And as I said, we take the x-ray, there is no paryngel
57:49
swelling. We immediately, we change the deposition of the patient after cleaning all my sets get read about outside the theater because it's almost contaminated from the mouth. and we'll use a
58:13
supplementation for posterior. We, all of us go to hand washing again to
58:24
be more sterilized
58:28
and I told to an anesthetist to give another dose of antibiotic for such patients to prevent infection because our program and disaster complications of such long surgery with combined anterior and
58:46
posterior approach at the same time to the infection
58:58
and the picture here is very desired part, yes, sir. If I can make a comment, if I can make a comment, there's a trend in, and I see it in our country, I'm not sure about others, or the young
59:09
neurosurgery residents. believe that they should do as many cases as they can, so that when they go out and are more experienced in our surgeons, they'll have all that knowledge behind them. But
59:25
there's no way you can do all the cases you need to do, just like the case you just exposed or you just showed us that you can prepare for it. And the first group of surgeons I'm talking about are
59:39
mechanical neurosurgeons, they're mechanics. What you've shown is what to me, I admire which is a thinking neurosurgeon. You're thinking about what to do, you're waiting for to solve Nancy's
59:54
problem of Hematoma, you're waiting. You're doing all the things you do, you can do to make it what you said safe. And I think the message to the young people watching this is,
1:00:09
you're never going to do all the cases you're going to see in life. And I'm sure Ollie, if you saw one of these cases before it would have been unusual, this is a very complicated rare case. And
1:00:22
the only way you can prepare for that is to learn the principles of neurosurgery and to be a good thinking neurosurgeon and not be interested in just mechanically getting the job done because that
1:00:34
would have failed And I compliment you on that and just an outstanding thinking process, outstanding execution of your plan.
1:00:52
First, actually, do you have any other comments? Not really, no, some time just to say what I see. Thank you. Yeah, I think Samir, maybe it's the time to wrap it up, but then come to some
1:01:06
kind of decision as to whether we would try this again with this similar format and you choose other people to present cases or, yes, Sarah and Dr. Ali to present cases again,
1:01:22
it's up to you. We are so grateful to Professor Epstein for her presence and comments and very important advices. Thank you so much, ma'am. I mean, I was trying not to interrupt and throw people
1:01:36
off. I was just trying to get questions answered as we go, but either format, I think, is perfectly fine. You did a great job.
1:01:47
Well, thank you. I think this is very eye-opening for both me and for Jim. I think Jim has been doing this with you for 20 other instances, especially with vascular, but I think what we learn
1:01:58
about you, what we learn about spine, and probably the most important thing is what we learn about our fellow surgeons across the globe is probably the best information of all. We're all interested
1:02:11
in what's best for the patient, and many of us are still interested in what's best for the patient, and trying to figure out what to do next, and how to do it better. Yeah, really appreciated
1:02:24
Professor Epstein. I should ask the attendee participant if they have any comments to the enthrabment surgeons. This is the time to ask your question. Are there any women medical students? There
1:02:40
is a lot. Good They are dominant already.
1:02:46
Okay, there's no reason that they could not go into neurosurgery. It's perfect. Women have very nice small fingers and good brain.
1:02:59
Yeah, for the medical student, for the medical school, yeah, I think the female are the more dominant, but neurosurgery, it's grown. I think the percent of female per each year accepted for
1:03:12
residency, it's already grown. Yeah, we have already more than 10 female neurosurgeons, and I think for the next few years, this number would be duplicated at least. By the way, the two cases I
1:03:30
present, these two cases, my assistants are two females and two different females,
1:03:40
and you can't case, and in another case, two different
1:03:46
under graduated neurosurgeon,
1:03:52
female neurosurgeon. Yeah, that's good. Most of you have three female neurosurgeons. Wow.
1:03:60
Excellent. That's
1:04:03
awesome. Well, that's the answer to you. And now they just did a superb job. And the message you have is not only a message for people in the low to middle income countries, but it's also a
1:04:15
lesson for people in high-income countries of intelligent, creative people who are making the most use of what they have in doing an outstanding job, both of you to be complimented. Thank you.
1:04:31
Thanks.
1:04:34
Yeah. I think if we don't have any more questions, we can wrap up today and we will discuss later All the speakers and all the moderators.
1:04:46
what's their potential opinion about the next steps. Okay. No questions? Thank you very much. I appreciate it. Thank you. Thank you everyone for your time. Thank you to
1:05:21
the President Ali. Thank you, Professors, and all the attendees. Thank you. See you again. Thank you. See you again. Thank you. Bye-bye. We hope you enjoyed these presentations. The
1:05:22
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1:05:37
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1:05:48
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1:06:03
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