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SNI Digital, Innovations in Learning, in association with the HOS Neurosurgery Lab in Baghdad, Iraq, are pleased to present the 21st SNI in SNI Digital, Baghdad Neurosurgery Online Meeting, held
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on January 20, 2024 The meeting originator and coordinator is Sam Erhos of 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
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it? The moderator and discussant for this meeting is Nancy Epstein, who's
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the clinical professor of neurologic surgery at the School of Medicine and State University of New York at Stony Brook in New York,
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and also the editor-in-chief of surgical neurology International.
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The speaker is Dr. Yasi Adil Tasa of the IBM Teaching Hospital in and Mosso Iraq.
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He will speak about the challenges in the diagnosis and management of symptomatic mumbar spinal instability in a limited resource environment.
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He has two case examples from his large experience, and we'll talk about how he does it with discussion from the audience Thank you, Professor Nancy, thank you to
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Sam, Professor James, for giving me this chance to give this lecture. I hope it will be beneficial and to hear from you a lot of things which are beneficial to all of us. In fact, I was
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in Petersburg at 2010, attending a program for Gamma Knife training on Gamma Knife about two weeks. I was in Pittsburgh, and there was a.
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Professor Ransfield in the UPMC. Okay, I choose for today subject some problem problems appearing to us or we are in facing during our, as in your surgeons, as the spine surgeons, in fact. Which
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is the inability to detect 100 that this patient is having any stable spine or stable spine for a digital disease of fine, for example, as one of the common diseases in any locality.
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I will start with this case, in fact.
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This first case, she was a woman, 60 years old woman, presented to me, from Craig Baghek for three years. This baghek radiates to the
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right hood.
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Neurogenic Intermittic Abdigation was also present in here. She has good control of centers. Her lower limb pain was more than her baggig. On examination, there was no focal neurogenic deficit.
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And the citrate-dig ratchet test was partially positive in the right side, which is the same side of radiation of her baggig.
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I did for her this MRI of Lambeau-Sager spine as you can see
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I find that she was having from the study tell you spine is still was a level of L3 L4 and
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L4
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L5 and
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this is the the previous one was the search the review and these are the absolute use of L3 L4 will you can see the standard clear and it's more clear at the level of L4 L5 and
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you can see also that the right nerve would more more affected than the left nerve root and there's marked hypertrophy of the yellow ligament on that picture do you can you go back to that picture for
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a second yes on both images the hypodence material door so lateral to the thickle sac is hypertrophy of the yellow ligament that's seen bilaterally yes yes quite clear and on the right side to the
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image on your left. There is some fluid in that facet joint at L3-4, also potentially contributing to a synovial cyst component that perhaps is not fully visualized.
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Yes. This here, Milo. Milo, and
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the
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IP answer view, call view
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And as usual, I
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did
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it for all of my patients, before seeing the dynamic x-rays of the spines, inflection against tension. As you can see, this is the affliction and the station. In fact, I find that the spine is
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not stable.
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No clear sign of instability, fragile parts, all of these teases was found in affliction at the station dynamics.
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My decision was to make for here decompressible mectomy and better form it of L3L4 and L4F5.
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Any problems? I'm sorry, this is the video from insertion.
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What? Were there any This is the video
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from This is the interoperative video
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found L5, L4, sorry, was moving. I repeat again
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Okay. It was unstable. So that before surgery, I decided only the compression of L3L4L4L5. Now I will do the compression of L3L4L4L5, but as far as the L4 is
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the unstable as we saw over of us, so that inside the relaxation of this patient.
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And these are the pictures from inside surgery, from the
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fluorocope, high fixation of L3L4 and L5
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After that, the patient was, okay, this is our command. Did you do a supplemental postural lateral fusion at that point? Is that where you place the bone? Yes, I put the lateral fusion, the
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lateral fusion, postural fusion, yes. Bye, one.
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How did the patient do? No, yes. Regardless of stability.
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Clinical instability is an important cause of low back pain. And number segmented stability important, but often unrecognized cause of chronic low back pain. It has been controversial and fully
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understood topic primarily because of the varying differences and users among the several Disciplines involve the treatment of spine's orders.
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Traditionally, one of the most obvious manifestations of number instability has been deterred to graphic diagnosis of spondulisthesis with increased significant motion reported in patients with
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chronic low back pain.
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However, number segmented stability, micro instability also has been supplied as it goes of chronic low back pain in patients without any injury to the ossius bone, a syspine. with a number of
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studies reporting crease and abnormal intersegmental motion in these patients.
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The stabilizing system of spinal column, these muscles, and the neural canal, the neural control unit. In 1992,
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you have defined spinal stability as a region of laxity around the neutral position of a spinal segment called the neutral zone And more precisely as decreased in
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the
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capacity of stabilizes of 20. There is no major deformity, knowledge can deficit, and no encapsulated pain The reservation is useful because it describes the quality of motion throughout the range
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of motion, lying solely on the total range of motion values for diagnosis
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It's also well-recognized.
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It's well-recognized in literature. It's well-recognized in the literature that if patients are awake and they have spasm, that you may not get evidence of significant motion on your flexion to
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extension studies. So that adds to the lack of reliability of these studies. If it shows motion, great. If it doesn't show motion, you cannot completely rule it out.
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Yes. A lot of other deception definition of critical stability, the ability of the spine and the physiology clothes to limit displacement so as to prevent injury or irritation of the spinal cord and
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the throat, including cardiac whiner and to prevent and keep stating the formative or pain due to structural changes. Why do mechanical stability refers to the ability of the spine to reduce forces?
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Now, for my patients, what was the problem? because I told you. their family, that the operation will be only just decompression without any instrumentation. But as far as you know, essentially
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we discovered that she was having instability, the decision changed. This means that the family
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will pay for the price of this accrues, which I need for fixation, because these accrues are not available in our general hospitals. And in fact, these patients are done in the general hospital,
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because most of them are poor people. They are not able to pay for the private hospitals, so that the operation will be free of charge, but they are obliged to pay for the price of this accrues,
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which sometimes is difficult for someplace, so that I told the family during surgery that your patient, I discovered that she has any stable spine, and
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for her she grows. And they agree, and they pay to the company, which left their support in our hospital, and we did the fixation, as you show No.
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A spine stability is subject of debate, despite multi-multitude of biomechanical radiographic and clinical studies, normal motion of the number of vertebral segments, but used to be a topic of
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debate because of the lack of standardized measurements in normal subjects.
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Radiography can detect instability, accurately 100 percent, critical instability and radiographic instability also has difficulty because of the overlap of symptomatic and asymptomatic motion
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patterns. Additionally, conventional radiography often is insensitive and unreliable in taking abnormal or excessive intersegmental motion
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Currently, no scientific evidence exists on how to make the diagnosis of laboratory, nor is there any proof of successful treatment. Surgical fusion operations may be useful in properly selected
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patients in situations for which the surgical approach has restated destabilization by lemmetomy and vasectomy If I apply planar radiographic techniques, promise better definitions for future
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diagnostic studies
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Then I give case number two, this is also a woman, age 58 years old.
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Well, it presented to me the chronic baggig for more than six years. Her
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baggig was more than her lower name. She had no focal energy deficit, control of factors. The state-state degradation test was negative for her. This is her MRI of number sacri-spine In fact, she
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was having also dynamic exercise, flexing extension, which showed to me clearly, clearly, that she was having an unstable or this disease at a rate of L4, L5. Unfortunately, this exchange is
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not so during surgery. During the theatre, they did not find them in the baggig of exercise This is also my low MR micron.
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The analysis, as I told you, not available, but should grade 1, L4 and 5, respond to the thesis. This
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was expectation of L4 and 5 with the compression and distraction reduction for her. What happened as surgery? There was a grade 1, L4 and 5 list for the thesis. With a fracture puzzle of L3,
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we're very clearly moving all posterior elements of L3 and even of L5. So that
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the three vertebrae were unstable, L3, L4, L5, all of them were unstable.
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The only one discovered by X-ray was L4, L5 flywheel, but as surgery, three rivets were all fractured.
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What we did for her, we did four half fixation of L. As you can see, L3, L4,
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L5 and S1 and decompression also. for the L4L5, as you can see, partial S1, lateral also, lateral bone effusion, posterior bone effusion, and post-apartively she was okay, I'm happy.
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Now, at the end, take home messages for all of my colleagues. Lumber spine instability is an important cause of low back pain. The diagnosis of lumbar spine stability is impossible. Even then we
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can exercise flexion and extension of lumbar spine that also we can also must need you. Don't tell your patient that your patient is probably may need fixation until you are sure about the diagnosis
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if you discover instability during surgery. In fact, this point is quite important that some of the surgeons told their patient your patient is need for fixation.
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Our patients are jumping from one neurosurgeon to other neurosurgeon to other spine surgeons
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Advice is so that they said for come come to me, they said, I visit two or three doctors, most of them or two, both of them told
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me you have your needs for. for fixation or glucose. But I saw their x-rays and their dynamic x-rays are looking stable. How they choose this, I don't know. So that, another important point that
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if I get my patient, you may need, you may need a source of fixation as a possibility, not 100. This
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will be a fixation point for this patient like that, for surgery, any bad thing, any level of pain, he will
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come to visit and
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say, Doctor, you told me, you made it a source. If you put the source for me, it was better. Now I will, but it will be needed for other surgery. I told him, you was
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not doing it for the perfect patient and now you are not going to need perfect station. Your bag is, other things like that, they're just simple as fast as possible.
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Another important point, there are other sophisticated investigation,
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they give us better information than MRR, that's fine with all these modalities, such
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as axial and thinking, which usually are, we are not doing what these are fine disease. And you know that their post will be, also when the patient will be great. But they may give us all the
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part of the suspicion of fractures if they are, if there's a fracture or no fracture. But as you know that for the first time, we are not doing a CT scan, unless the patient was having, for
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example, a shell in his body or something, he could prevent him from doing
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MRI. Lastly, prepare yourself for the rehabilitation at any time in doing disease-inspired surgeries. With regard to the availability of a fixation system and the type of patient, Exchange system
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availability. in any hospital should be present. In the past, it was not available. Now, it is available at HBO hospital. The companies are bringing their systems and are all sterilized in our
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hospital and they are ready for surgery, for use, I mean. If we are due to surgery, it's covered that this place is needed for a fixation. We will tell the family and we will do a fixation. This
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is, I mean, availability of fixation. And also, I mean the type of patients, the type of patients that this patient is cooperative, he can agree, my decision, whatever is it, even if I'm
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obliged to change my decision during surgery, for example, like the first case or the second case,
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he will agree,
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I mean, the type of patient type, polite patient, good patient with ethical patients. Thank you. And thank you very much.
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I should say first that you are traveling and that's why you have some internet issues and some connection problem. The voice sometimes is not that clear, but it's understandable. That's, that's
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the good thing. We really appreciate this presentation. I would
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like to listen to Professor Nancy now your opinion And if you need any image to see where to comment on just for the benefit of all the attendee. Yeah. Thank you. Dr. Yasser and the mic is yours.
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Professor Nancy. Now, I think that the, the conclusion is a very important one. And that is when you're dealing with degenerative, especially lumbar disease, I think the role of obtaining a
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preoperative CAT scan is a very, very important role The other thing is not only will it pick up a lysis defect or other fractures, but you also have with CAT scan the option of doing essentially
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affliction and extension CT scan because the CAT scan is just gonna take you seconds. So I think CT scans are extremely valuable plus the fact that you can directly measure based on the CAT scans the
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size of the screws that you should have available in case you want to do a fusion or you need to do a fusion The other comment I would have is especially in the states, I think we really are
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obligated pre-operatively to have the full discussion with the patient prior to the surgery about the options for or against having a fusion done on here. If you haven't discussed the fusion
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pre-operatively, you might have to do the decompression alone, Wake the patient up, bring the patient back another day. and then do the fusion. I think the other thing too is, if you have an
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older patient, you have an option in older patients with more degenerative pathology of considering using the intraoperative lamina that you've harvested and doing a non-instrumented postural lateral
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incity fusion without instrumentation
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So, Dr. Yasser, I think these are three points. The first is Dr. Nancy said that it's a standard for them to do CT scan. I hear all of them. Yeah, can you explain why in Iraq it's not always
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available. It is available, available. But as I told you in my lecture,
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the patient to go more more and more further investigation is causing to the patient safe, flexing a station, dynamic exercise. And this we have for example, dramatic
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CT scan.
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Professor Nasi Nasi, do you hear the comment or? Yes, I can hear. Okay, okay, that's good
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Jim, what were you going to say? First of all, yes, sir, those are very excellent presentations. On a common problem that I'm sure Nasi will tell us is treated in many different ways. And what
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you did was very practical and very reasonable. I had some in the first case, I could see it on the film that when you operate on it, it was a tremendous amount of motion, which led you to do the
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fusion. And that seemed reasonable. And on the second case, obviously you had some idea beforehand with the Spondylolus thesis. What I was going to, and I think all the things you showed were
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very good, very interesting, and I think very appropriate I was, I think Nancy is an expert in this, and I'm sure you are too. You mentioned that in your area that some of the patients cannot
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afford some of these procedures. And that's understandable. Nancy has done some work on this. Nancy, under what circumstances? And this is true for people in rural Africa and in other parts of
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the world that's where they don't have the instrumentation.
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can you treat these people by using a bony fusion and try to stabilize them externally and get similar results because it's cheaper and and you don't have to use the instruments. I know in our
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country everybody goes to instruments but I think when Yasser is saying maybe we don't need all that so what's your point about that and then Yasser maybe you can comment and see I think that first of
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all there has been a tremendous amount of literature on this topic and a lot of the studies show that the outcomes for a grade one spondylolisthesis at L4-5 for example are comparable if you do a
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decompression alone or a decompression with a non-instrumented or instrumented fusion but number two for years especially if you have access to an operating microscope If you can work from the
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opposite side of the OR table and undercut that L4-5 facet joint on either side to get lateral and foraminal decompression, you can often get away with a decompressive laminectomy alone without
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sacrificing the facets in these patients. And a lot of them will do very well from that in and of itself. For those who you think are really unstable, the bone that you harvest during the partial
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laminectomy of four and five, or if you've done a total, save the bone, clean it, and then you can do a posterior lateral, non-instrumental or insight to fusion, placing it over the transverse
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processes. And three, four, five, six months, take your choice. Different people are gonna put you in an LSO brace or not. That can also be very effective. Lots of times it's more effective
26:33
your older versus your younger patients, but it does not always mean that you have to have an instrument of fusion. Instrument of fusion have become the vogue, but it does not mean that that's the
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end all, or that's probably the only way.
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Yeah, I'm sure what your thoughts about
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that. In fact,
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the past before the era of
27:04
zegruz, we were doing minimally anti-compression and the freeing of the new vlogs, and they had the patient to address the belt for about three months, for example, and under follow-up of these
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patients, and they
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were able to understand that we have no secluse, so they were except the idea of belt for three months. But now, all of the patient, all of our patients, they know that we have secluse, And we
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are doing a lot of fixation and fusions by using this sucrose and the other bars. And they will not agree that I tell them, I found your spine was fractured, you went to this, the belt for three
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months. David said to me, why you did not do it for me?
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Well, it was rapid, rapid action and there is also be more, more rapidly to
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get rid of my pain. Three months already since. If I'm not of extension and I discovered that they are having fractures. How did you have some thoughts or comments about, I mean, this is a
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procedure that can be done differently all over the world And
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Yasser has done an excellent job. What are your thoughts about
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Shur Hari? I'm very much impressed with the work Yasser has presented and he is in Mosul with a difficult situation. He is in, and I'm interested to know where did he get his training first of
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spinal surgery? He'd be so good.
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In fact, I get my thing in India, at the India Spinejia Center, I sent from
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they have heard at about 2009 I spent, at the end of 2009, I started of 2010. I spent at the India Spinejia Center for
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two months. I learned everything about the spine. In addition, we are just always in contact with if you know him, Professor Mamet Zileli, from Esmeer, from Turkey. Now I'm in Turkey, in
29:26
Istanbul, we are attending at Melbourne University Hospital course, Okay, everybody, of course, about
29:32
your bike has fine. for Syrian and interior. So that we are not only training only for in India, but continuous training and learning from any other
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programs.
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Well, in our time, Jim, we didn't have fixation at that time with very much limited, especially the time of sanctions. We used to do just the usual work of maybe four a minute, to be that's the
30:03
most
30:05
elegant, perhaps, of the surgery that I've done. Compression and things. So my question too is, are you using a microscope on these cases? You have access to microscopes? We have a microscope,
30:19
and we are sometimes using it for deep operation.
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Sometimes, or always, or what was that answer? Also, in fact, according to the hospital,
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In our even cities hospital, we have a rescuer, we are using it, or we are using the loops. If it is not like a scope. 'Cause my experience is that, you know, the microscope is so much better
30:45
because not only you can see what you're doing, but it also allows your assistant to see what you're doing and better facilitate helping you. This is particularly important if you are in the lateral
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recess and you're foramically working and you have hypertrophy of the ill ligament or even a synovial exist extending foramidly, it's the only way I think that you can best decompress laterally and
31:10
foramidly without sacrificing too much of the facet joint and therefore enhancing or increasing the instability while you're doing the decompression. So I think using a microscope whenever you can,
31:23
both for you and for your assistant is certainly much better for the patient rather than leaving a microscope in the corner of the room or something like that. No, once it's available, we are using
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it. Once it's available in the hospital, we are using it. But if it's not available, we are using the loops. Yeah. The loops, instead. In fact, we are doing a lot of surgeries. We are doing
31:43
a lot of work to do surgery, and T-leaf cages, we are putting them. We did the scoliosis about, as a group of spine disease, a spine positive if you are doing scoliosis surgery The cervical spine
32:02
is also, we are doing
32:05
ACDF, for example, and also cause as well.
32:11
And even the kind of cervical junction where we are doing surgeries for this case, although they are available,
32:21
it's not. I'm sorry, Yasur, how much does it cost for the patient? as it cost for the patient. to pay for the instrument or
32:35
the instrumented fusion for getting the screws and devices. Is that very costly or in your area or is it not so costly? How does that, what is the price? What is the, how does that affect the
32:50
behavior? It depends
32:53
upon the type of the cyclones. For example, we have three cyclones from the company called Nova's Mine The price of eight cyclones is75.
33:03
While for Mediterranean, Mediterranean, the price is130. This is
33:11
for the, the rate of the cyclone only. The bar, the bar price, according to the amount of, I mean the levels. For example, four cyclones by75 means300 plus100 for the
33:29
bar, lateral bar. equal400. If a
33:33
Mediterranean, no, the price will be more.
33:40
134 for each secro, and the bar will be more and the Telif case, for example, from the Turkish company, we are using it by about250, while for Mediterranean, equal about600
33:55
for each Telif case. So that in general, as I told you, in the general hospital, the surgery will be free. They will pay only just as a close. While in the private hospitals, these searches,
34:07
for example, putting four secreuse
34:12
with T-leaf cage and two
34:16
lateral rods for connection, four secreuse, one level of fixation, this will cause the patient about3, 000 in
34:27
total.
34:30
I mean, the hospital's tight and the investigations and the drugs and the supposed until of case.
34:40
What's interesting here is in the US, if you are in a hospital, the cost of the instrumentation is borne by the hospital, but then the hospital multiplies the cost of those screws, that
34:55
instrumentation, somewhere between four to five to six times, and that's what they end up then billing the insurance for the patient. So it's a very different system here.
35:08
We have no insurance, still not. I just want to mention that, yeah, exactly, Dr. Yasser, that there is no insurance system and there is no taxes. So those numbers should be discussed directly
35:22
with the patient and the patient will pay that directly from this pocket That's why Dr. Yasser is explaining that, This is the direct discussion with the number of the patients so he can understand
35:35
and can agree, yeah. Yeah, but if you go to surgery, how do you make sure you have access to those screws unless you've spoken to the patient ahead of time and they bought the screws so that
35:49
they're available in case you need them?
35:52
In fact, these companies are having their sets There is so
36:04
much of exception and the screws, they put and all the sizes, for example, six by 40 by 45 by 50 and et cetera. The cages, delete cages, the cervical spine, cervical for ICDF cages, everything
36:20
is available in the hospital and sterilized Ready for
36:28
surgery at any time. The patients will only go to some office outside the hospital. They will pay for this, the presenter of this of this company, the price of the sucrose and roads or, okay,
36:41
but they are available in the hospital. Okay. Do you use any company by companies, not by the government? Yeah. Do you use any kind of intraoperative monitoring for any of these cases,
36:57
somatosensory vote potentials, motor vote potentials, electromyography, or EMG? Yes, we are using this in case of
37:11
number one, and what we are using also, the
37:17
per supportive EMG Okay, we have some specials in this. Why by a simple, simple disease like this kaktomi or spines, you know, we are not using the EMG.
37:31
And I ask one question, Dr. Ali Adnan, I think you just joined, you joined us a little bit ago and I think you heard the presentation. Do you have any comments from your experience?
37:45
Thanks, Dr. Adnan. No, I'm Dr. Yasar Kavar.
37:50
The old subjects, yes, this is all obstacles, the instrumentation and in governmental, especially in governmental hospital because the most of the patients are poor and must pay
38:08
for the company, the amount or the prices of this group, always every week we facing the same problem and some patients are very poor, cannot pay any
38:29
any prize for the instrumentation. And this is a big program and a big deal. That is why we modified many things like use of a bony graph as you mentioned previously or sometime we modified what the
38:48
available secret as you will say in my cases by shortening the secret and et cetera
39:02
I think,
39:04
thank you very much, but I think Samara, what Nancy has and what Yasser have told us is
39:14
for viewers from all over the world, from the low income to the high income countries is still there's a standard procedures which we've done for many years that's what you did what I did, that can
39:27
be very effective using bones for fusion. And as Nancy said, if you follow that out for six months or so, the results are the same. And then in other places, you can, you can buy various
39:39
instruments and there are various levels of costs. And, and then we get into more complicated ways. I am sure Yasser used his own vision to place the screws. Is that correct? And you didn't use a
39:52
a
39:55
right? You used your own experience and to place the screws. You know where you're working. Is that right?
40:04
Yes. And, and, and, I
40:15
am very, very, very, very, very, very, very country. In other countries, it's motorized and done by robots and the expenses get more And then we get into the area where people may be doing it
40:25
for questionable indications, Nancy. was quite obvious from what Yasser, the two cases he showed, that there was mobility. And you could see the potential for abuse of, well, I don't see it on
40:41
the x-rays, but it's a mobile at surgery. I mean, we could see it. It was obvious. But so there's a wide range of treatments everywhere in the world.
41:16
And depending upon what your resources are, you can treat it well. Is that correct, Nancy? I would say that is correct. I think that one, one variable that you probably don't see that we see is
41:17
we see numbers of cases, lumbar spinal stenosis, neurogenic quadrication, bilateral radiculopathy, MR, no evidence of instability, flexion extension films, no evidence of instability, yet
41:19
these patients end up with multi-level, transferaminal, lumbar antibody fusion cell 2-S1, L3-S1, L4-S1. So a lot of surgery here in the States is being done. That's unnecessarily extensive. Do
41:34
you see that where you are?
41:42
Too much surgery is done that's not done. In our country? Yes.
41:48
Yes, yes. In our country, we call them as trade doctors. They are not the human doctors. They are just doing fixation for any disease. Fixation,
41:59
fixation, fixation, fixation. All the fixation.
42:03
Many patients, as I told you in my lecture, they called five doctors, all of them told me that you are in need for fixation But I examined this patient very carefully and see their MRI and their
42:15
X-rays, flexion, fixation. There was no eye size of a stability. I did for them the proper surgery without any fixation and they were getting very very well without any fixation. But from what
42:28
you're telling us, with your selection process, there are probably many patients that you are seeing that you were saying from the start, You don't need a fusion. you operate on them, you
42:41
decompress them only, you don't do a fusion, and they do just fine, and they did not need a fusion. So that's probably a fairly large percentage of patients that you're seeing, who you're saving
42:54
from having an unnecessary fusion.
43:03
But not only an assistant fusion, many patients came to me with an assistant surgery. You know that this point is easy for example, this will resolve about for example, six weeks, for example,
43:14
after conservative treatment limitation of
43:18
the dangerous movements and everything This is what I give to my patients, I believe in. Excellent job, just terrific job and that relates to everybody around the world. Terrific job, thank you
43:37
very much.
43:41
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43:45
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44:02
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44:19
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44:28
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45:02
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