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SNI digital innovations in learning and association with sub-Saharan African neurosurgeons are presenting the sub-Saharan Africa International Neurosurgery Grand Rounds, which will be held in the
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first Sunday of each month. A title of this Grand Rounds is Global Solutions to Clinical Challenges in Neurosurgery
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For this grand rounds, a major topic will be management of penetrating wounds to the skull presented by Professor N. J. M. McGuambee from Kenya. And a guest speaker discussed at Nancy Epstein
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discussing practical solutions for spine surgery. Other discussions come from Africa, Argentina, France, Iraq, Persia, and the United States. Moderators are Estrada Bernard and James Osmond.
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Ladies and gentlemen, esteemed colleagues, welcome to the global solutions to clinical challenges in neurosurgery. This is the first in a series that's being sponsored by SI Digital. I want to
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thank Professor Osmond for putting this together. This is a great opportunity to to transcend geographical borders and bring people together to promote neurosurgery and make a difference around the
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world. This is a conference that's for sharing knowledge is a collaborative space and I
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encourage an active participation by everyone. We've privileged to have experts from Africa and experts from around the globe essentially collaborating. So I think this is exciting and looks forward
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to moving this forward. And thanks again, Dr. Osman. And
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also just want to mention that we've privileged to have Dr. Nancy Epstein, who's the editor-in-chief of surgical neurology in the National Journal, who will be making some special presentations and
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actively. engaged in our program. So welcome, thank you very much. And Jim, if you'd like to say anything further, please do. And then we can start the program. Okay, I'll just take a few
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minutes and introduce everybody. First of all, our gratitude is to Gilbert, who we spent 30 years developing educational programs through Africa, his commitment is unparalleled And he's just done
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a superb job. And with his advice, we're proceeding and Professor Nogwambi, I think everybody knows is an distinguished career and is a major national, if not a clinical figure in Africa and
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neurosurgery is a great success. Great success. Nancy Epstein, everyone knows is a Venezuelan surgeon for non-sub.
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40 years has written more than probably most people in academia and is editor of surgical neurology The
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University of North Carolina was trained at Duke, and has been very instrumental in helping us get going here. Said Konsari is from Persia, was trained in France,
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hospital was a hospital, you were trained in?
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It's a very modern hospital on suburb of the Paris. And so you'll very notice that. And it's now in UCLA. Samor Hose is from Iraq. We have people from five continents on the talk today. And he's
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been extremely active with young people. He's got a program we have to hear about in the future. He's mentored a thousand young people. so they can move on and get into various phases of medicine,
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a neurosurgery. He's a hybrid neurosurgery or both vascular, interventional, he's
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had great experience with trauma in Iraq and
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very presentations before that have been, a person next to him was head of
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intensive care at Johns Hopkins and said, we ought to all listen to you, you know more than we do
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Jorge Lasser of his pediatric neurosurgeon from Argentina, he's traveled all over the world as everybody else here and has just got back from China. So, and we have another person that's gonna join
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us who is Shanda Shaker, Dale Pujari, he's in Bombay. He's head of neurosurgery at the Bombay Hospital, been involved in pediatric neurosurgery up in Toronto.
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with us for a while, and also is an adult neurosurgeon, a tremendous experience and very interested in the kinds of things we're doing. So without further ado, let me tell you a few things we do.
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We want a lot of discussion and we don't want you to take it. And personally, it's something we believe is different than what most teaching is Experience has shown that if people just listen to a
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lecture, they get about 20 that they learn. If they have a lecture with some slides or information, they may learn 40 or so. If they got lecture slides and discussion, the learning goes up to 90.
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So we've done that. I know Jill Barrett has found that in his work in Africa And so
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people may ask questions and we want them to participate so they learn something. Okay, Professor, would you like to go ahead? Okay, I think, thank you very much, Professor Osman and
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your team for coordinating this. A major, major step forward, and it will help us a lot from Sub-Saharan Africa to be able to have a discussion exchange cases which will help manage and sometimes
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exchange cases which would like to manage and get opinion from experts. And therefore, this will be very, very beneficial to practicing neurosurgeons as well as to residents. And we hear from
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Nairobi, Kenya.
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As you can see, what I'll be presenting will be what effort of
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several neurosurgeons, myself, Dr. Musau. Dr. Kibwe, Dr. Akuku, Dr. Olunya, Dr. Mohangi, Dr. Kessar, Dr. Gichuhi, who is our own ophthalmologist and
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Dr. Viambo, who is a radiologist, Dr. Jiro, Dr. Mohan, and all these neurosurgents, initially who are based at Canada National Hospital, and some of them have now qualified and they're based
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at Moi Teaching and the Faroe Hospital in Adorit, and of course myself have moved on, and I'm no longer at Canada National Hospital, but I'll be sharing this case which we managed with my
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colleagues about 10 years ago, two cases.
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We shall present two cases of penetrating head injury, which you managed in Kenya As an example of penetrating head injury, which we encounter in our region, and where management effort by the
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neurosurgeons, neurophthalmologists, and neuro radiologists.
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Our first case is a male, age 24,
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who came with a history of assault at his place of work.
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Our patients tend to present late, but fortunately this patient came within two hours of assault, so it was quite fast His vital signs were stable, he was confused, he was bleeding from the wound,
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and there was a knife protruding from the left frontal aspect of the forehead.
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His glass of comma scale was 14.
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Right eye was normal, but the left eye there was sub-conjectable hemorrhage with chemosis, he was examined by the ophthalmologist who confirmed that the eye was functional and had not been.
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involved in that injury, although it was the knife had passed very near it.
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We started in the usual treatments, put in antibiotics
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and all the usual things, and then we did a skull x-rays, which we would like to share with you.
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These were the skull x-rays, which we did. And as you can see, fortunately whoever stabbed him never took out the knife, and probably this may have helped him a bit, because when he presented,
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he had this knife, which was there, and it hadn't been pulled out by whoever had assaulted him. We did a plane radiograph, which you can see there, and of course it shows the knife going right
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there near the base of the skull,
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very deep deep and then we had the advantage of doing a city scan of the head, and you can see the images are not so clear, but again, it
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demonstrated the extent of penetration of that knife, and how it had gone almost into the seanoid air sinus and the length of the knife.
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This again, does the city scan, you can see it there Now, we proceeded to prepare him for surgery, and you can see there, when he has been anesthetized, and we're able to take the left top image,
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you can be able to see the knife there, how it penetrated on that aspect. And what we did is we raised a very frontal craniotomy. You can see there is traditional incision, which was made there,
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and this incision then was incorporated to involve the site of. nutrition of that of that knife. I just ask a question for a minute. When you were doing this obviously you want to leave in the
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penetrating engine. You want to leave the knife in place. Did you think of you know cutting it off the knife was left in place. The knife was left in place while we met a patient. My question is
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could you have cut off the handle? It could be easier to prep and drape the tip of the knife that you leave in place rather than the whole handle and everything else so that it's a more sterile field.
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Yes, okay. That's a good point. That is, could we have covered the, but what you notice is the
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dropping which we have done on the wound. If you check carefully, you find the dropper which you have planted on the wound. It has We didn't cover the knife itself, but it has isolated that side.
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But that's a good point you have made. That would probably could have covered there. The handle erupted before making the decision. Yeah, I would advise not to even touch the knife. I have a
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different point. I would advise not to even touch the knife as you did. Because in the hands of residents and trainees, one important point is to always let them know that they shouldn't touch
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anything. In trying to touch or cut it, you cause more damage because it's going to move. It's going to cut more structures. So I would advise that other ways.
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Well, what was very obvious with this patient? The knife was very well lodged. So it was hardly more movable.
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And the patient came working with the knife quite lodged in. I mean, it had impacted very well moving. Therefore, that's a safety aspect which we had as we prepared him for surgery. But as you're
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doing the operation, then you have to have somebody underneath the drapes pulling out the knife so that you can follow it down, correct? Eventually?
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No, I personally am not there, but I did
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It's not, they wouldn't have done that because the knife is a strong knife and cutting it is going to cause a lot of troubles and holding it is, I mean, just leave it as it is and keep working
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towards it until you get to the base and then you deal with it.
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Okay, I think
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that's what we did. I think that's what we did. The damage and exposure of surrounding nerve tissue eventually as you're following the track down Well, let's let Professor go ahead and finish a
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little and then we can talk, we can talk some more, okay? Now, if you look, if you look
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from the flap which we have raised, we raise the flap and we incorporated, we incorporated the, the, you know, we extended the incision so that we incorporated the entry point of the knife.
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Right. And then after we had incorporated the entry point of the knife, then we cut the holes to raise a bone flap and nibbled around the knife. So where the knife had penetrated, we did like a
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crannyectomy so that we had that loose end there. And then after that, of course, removed the bone flap, removed the bone flap. So after having removed the bone flap, then now we're able to walk
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around the edges of the knife and followed the knife downwards up to the, with hemostasis, up to where it had lodged itself and were able to actually move it safely without any problems. And with
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this patient,
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we didn't do any other investigations. We didn't do like vascular studies, you know, like with the next questions, which I'll share with you. So we didn't do vascular studies. This one, we only
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did the city scan and from the city scan And from the pinion of the of the of the knife, we were quite positive. We were quite sure that there were no vessels which were involved around that area.
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And fortunately, fortunately, you know, we are,
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we must say, some of these surgeries, of course, luck is always there. So I think luck was on our side. So we did, we were able to complete that and return the bone flap, anchor it And you can
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see from the left lower image, you can see the knife now, which has been removed. And you can see from this, the bifurntal cranial tummy incision, together with the
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extension, which we did to incorporate
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the cytopenetration.
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And that is how we worked on that. And of course, from the images which you'll see on the right, the patient,
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after the surgery, he was extubated You didn't keep him and
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intubation, he was extubated. And he was able to make a good, good recovery. You can see from this - now, this is the incision which we went through. You can see that's the incision where they
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had been stabbed. OK, you can look at the left image, and then the incision which we made with the effect. And in 710 days, he had recovered And you, well, we'll say that because this was the
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frontal lobe. you know, he was very, very fortunate. So therefore, you can see he's able to move his limbs quite comfortably and eventually we were able to let him go home.
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And I can stop there and get any comments on that case. When you put your initial CT, you could have done a CTA to
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CT angiogram in order to get a look at the vessels Yes, we will. Did you do that in the future? Well, it says those challenges sometimes in our setup because these patients pay for these
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investigations and each investigation costs money. And these patients usually don't have insurance cover. So sometimes we find that we would like to do some more investigations, but we're hindered
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by financial constraints. Hi. Excellent.
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Jorge, you want to say no, I had a similar case here in the United States, like 20 years ago, somebody coming from southeast Los Angeles, and we proceeded more or less was a shorter knife. So it
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was possible to actually do the prepping and raping, similarly to, I mean, without the consent of Dr. Aepstein race, and it was a child, a child was a 12 year old, a child, but sometimes not a
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child. And in rounds after,
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I was chastised for not having done an angio before. City angio or for a plane angio. And
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I always warned, there is one of those cases that started in it in my mind. I said, how lucky we were by when, after all that exposure, there is one moment that you have to pull the knife with a
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blade. everything like that. So I, in one sense, I agree with Dr. Epstein's absolutely that perhaps in the ideal situation, in the ideal circumstances, as I had here in the United States, not,
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not somewhere else. An angio, or a CT angio, is very informative. On the other hand, I
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am extremely pleased that this gentleman, as my patient did very well, because he's a boy who should, but I was reviving at the nightmare here in the United States, not in sub-Saharan Africa. So
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yes, maybe angio, or CT angio in the ideal condition
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is something, is something useful to keep in mind. But thank you, Nimrod, because we now have two cases without angio, a knife that as well.
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Yes. Thank you.
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It's better to be lucky than good.
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So we are lucky.
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Yeah, I think that's true. I have a question for the professor. I think the moment of truth is certainly when you withdraw the knife and I was concerned that that knife could have been perhaps in
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the cavernous sinus So at what point did you withdraw the knife? It sounds like you made an exposure, at least for part of the way that you exposed all the way down to the near the tip before you
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withdrew the knife. But what was your process? As I said, this was a teamwork. So what
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I would like to emphasize is that this surgery was done by the residents assisted by the neurosurgeon, who was on call, and the resident who did This is now a neurosurgeon in Eldred. That was Dr.
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Mohan and Dr. Jiro. They were the two residents who really handled this case. And they were assisted by the neurosurgeon who was on call. And the knife was not withdrawn. The knife was dissected
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up to gradually around it. So a dissection was done around it with him of Stasis until you reached the point where the blade of the knife, the tip of the knife And that's aged in now, the knife was
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carefully. It's also interesting 'cause the knife, the knife clearly tapers a lot. So basically they followed it down with cotnoids along the path of the knife, correct?
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Yeah. Okay. And of course, as you, as now retrospectively, of course, as I said, we were just lucky because, you know, we didn't do ancho and
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we didn't know how was the vascular challenges
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whatever reason. We didn't know that with this case, with this case, we're just lucky. And as I said, sometimes these are the constraints you work under. And what happens is when now you reach
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that level and you encounter a vascular problem, then now you see how you handle it at that stage. But in this time, you could actually have interventional radiology available in the field or with
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you to embolize or whatever tricks they needed to help you if you have some bleeding, correct? No, they don't. Do you have an eventual radiology capacity there? No, I don't know what they can
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hear
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me. This is 10 years ago. We had not reached that level yet in our interventional work. Now we are quite advanced in some of of this work can be shared with our colleagues. Anyway, let me see if
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I can make a point here.
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Go ahead. I still, even up to date, even if it's today, in my practice, fortunately, I've encountered a lot of these stab wounds, both in the head and in the spine. And the principles are
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always the same. You don't try to move that knife. You don't try to touch it. And then the hands-off residence, they become so enthusiastic, or if I could use the word, oven enthusiastic, that
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everybody's like, okay, let's touch it, let's do this And the more radiology you try to do, yes, you get good information. But the more the risks you stand of moving that knife and cut
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more. That's very good. Into eight. Now, interventional radiology in our part of the world should not be a conventional, yeah, stick. I think that we should always look at the context in which
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something is being done, what we have to utilize to do that, and what are the basic principles And I cannot even if it happens to do it. Professor Munger, I was still concerned with what they did.
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Keep it still, go in as much as possible, dissect through it, get into the base, remove it and you will be very fine. But if you try to do
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many more things, then you get more into trouble. I can remember years ago in New York City, at St. Vincent's Hospital, the patient was admitted and they had a Dixie cup on their back and
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actually radiographically did a myelotomy. And in that patient, we actually did that patient prone, kept the patient awake, used local anesthesia, followed that by down through the cord, using
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local anesthesia, took it all out and the patient ended up neurologically intact. So the whole point is yes, you have to take off the Dixie cup, but don't remove the penetrating object. Terrific
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discussion because these are emergent problems And that's the first thing is people. So what should I do? And I think we've had a good discussion about that. Professor McGuambe, I think your
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people did a superb job following it down and seeing if you could do that. I know you have another case. I just want to stop here for a minute. Welcome. The people who have just joined us,
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where this is the first sub-Saharan International Neurosurgical Grand Rounds Professor Agrombi from
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Kenya has presented this case that they had some years ago with a penetrating entry. You can see the knife there. And we had some discussion as you remove this right away. They did a craniotomy
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around it and then followed it down. And then we were able to remove it under direct vision. And that summarized it correctly, Professor? Yes, yes. You have some areas correctly I'd like to
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welcome Griff Harsh. Griff, it's nice to see you. I know you've spent a lot of time also and you're donating your time in Africa. So we appreciate your being here. Sam or you've had a huge
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experience in Baghdad. I don't want you to give your talk. You were gonna give a little later, but what's your, you've had a huge experience with some penetrating injury. Do you have some
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comments at this point? You wanna wait till later?
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Yeah, I think I like the description of the case and to be focused on discussion and maybe similar to Dr. Lazar, if I have very similar case, maybe running more through skull base, I think with
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the same made a model of the
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knife, it's just interesting.
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And yeah, I think few points mentioned by
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Dr. Mangonbi that the late, only patient usually presented late because the system and the emergency cars and those things is not that well settled, usually in in in in peripheral area or the area
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draining multiple injuries. And basically those are transporting car, not really emergency cars. So being lucky for the patient is also because he's he will be exposed to many people through the
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way until he reached the emergency department. That's that's what usually happened around the world. And I would be I totally agree with the NGO thing that most of the patient you will lose follow
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up. And you don't have a long term follow up for Sedonia or something like that in general. I would be interested to know if there is a name and antiseptic technique like out of guideline because
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sometimes we use something that's sometimes hydrogen peroxide, sometimes local, gentlemizing, regardless of the guideline, but those are expected to be not to clean surgery. So whatever available
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we may use, what's your experience?
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Now, the, as you said, many of these cases which we see actually come late. And this was a very unusual case because it came two hours from the time of trauma, of assault. And this was one of
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the advantages that after the surgery, the complications, we didn't have this issue of complications, as would have happened if the patient had come late. So that's one of the great, great
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advantages we have. But then we must bear in mind that in our setup, many of the care things are usually referred. And usually there will be, coming six, eight, 12 hours, or even 24 hours, let.
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And then sometimes some of these cases, it's almost very difficult to refer them because of the nature of those injuries. And you'll find that in many situations in our setup, fortunately, we have
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neurosagions now in many of the peripheral areas. So they may be able to do the initial management of the case, but this is a very complicated case with a lot of backup. And therefore, the
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neurosagions in some of those peripheral hospitals will still face those challenges. So the advantage we have with this case is that it occurred in Nairobi. And Nairobi is a very, very metropolitan
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place. And with a lot of advantages of transport, et cetera. So this patient was able to be brought to hospital within two hours from the 10 years salted at his place of work. We still don't know
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why, why, why it was a sort of it's place of work. That was this as we would find out. I just like to address words. And then the other one is that we don't usually use topical antibiotics. So
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we just, even if the patient comes late, we just manage, if the patient comes with a wound, which is less over 24 hours Because we just manage as would manage a potentially infected wound. So we
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don't usually use local antibiotics. And the use of hydrogen peroxide We again, during my teaching with the residents in the alias,
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we reserved that for very, very special situations, but it was not, not routinely used hydrogen peroxide to comment on the hydrogen peroxide because In spine surgery, actually, we routinely used
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it. My father was a neurosurgeon. He was trained by David at Albert Einstein in the '40s and the '50s, and he used it for decades and we've used it for decades. So at least in spine, we haven't
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had any adverse reactions to it, and I think it really helps. And it hyperoxygenates the wound as well. Okay.
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Anybody else want to ask you a question? Yeah, Dr. Bunting, thank you very much for sharing this idea, a professor. It was very nice. And we have seen it once in a while, but believe the
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problem we have in Los Angeles, mostly gunshot wound because they have more advanced and everybody shots on the head. And that's a different story. And the other thing that Dr. Epstein brought is
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that I remember in France, for the brain abscesses, we had to irrigate them with beta dye.
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because better time is very safe for using on the brain. So maybe to consider that for irrigation of the gunshot wound or on the stab wound like that. Thank you very much.
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Any comments? Anybody else want to comment? Because I know you have a second case professor
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I'll
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ask a question.
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What was the duration of the antibiotic treatment and what is your recommendation? There are many guidelines that recommend antibiotics but it's not based on prospective data. Most of the data is in
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this case series. So
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it's not really clear and there's some controversy about using antibiotics prophylactically. One of the concerns is that you might select of resistant organisms.
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that notwithstanding, what is your customary practice for duration of antibiotic treatment? The duration, now the guidelines on with this type of patient who comes almost within six hours of trauma
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is to consider it as a case where you give antibiotics during induction and then continue up to about sometimes 76 hours But we don't prolong it more than that.
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What if you have a drain in place? Are you using it until the drain comes out?
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We don't leave drains this type of trauma cases because there's a little more indication for leaving a drain most times. Okay. Do you have problems with post-op seromas?
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Well, I don't know, it's, Remember that leaving a drain sometimes in our situation. Sometimes a drain brings more problems than solves the problems because the environment, we work. So you have
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to really, because again, the type of drain which we would have to leave is like the vacuum drains, the patient has to buy those, and they're very expensive. So you find with those. We're just a
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gravity drain, a gravity drain, what would be safer because you don't want to suck out the spinal fluid, right? Yeah, that's a good point. That's a good point. Okay, most of the trauma cases,
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we don't live drains. Okay. So, um, uh,
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Australia, I think we have a second case. We had a terrific discussion there. Professor, you have a second case. You were your group wanted to present, is that correct? Yes, I have a second
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case. Another very interesting case. I can't penetrate to ninjas. Okay. Now, this pediatric case is a one and a half year old child and the history was from the father. Unfortunately, this,
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again, this was quite sometimes about 10 years ago, 2014. And what happened is there was sort of like terrorist attacks, which were taking place, not really, I wouldn't really call them
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terrorists, but thanks, people shooting, shooting in a neighborhood. And as that was happening, the mother of this child
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wrapped herself, covered her child so that, you know, the guns which were being thrown into, throughout, didn't enter the child. And then the mother, the mother, the bullet went through the
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mother and the mother died. And then the bullet now went to the child, hit the child. So at that stage, now it was a law velocity at a law velocity. So then the child, the bullet entered, the
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child didn't lose consciousness But then when people went to the front, the mother had been killed. and the child was, she was holding the child with this bullet which had entered into the head.
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The child was very stable with Jesus 15 of 15. And there was a scalp point entry at the site where the child had been, the bullet where the bullet had entered. And now this was about 300,
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about 500 kilometers from Nairobi because it occurred in a
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town which is a seaside town called Mombasa So this patient now was referred to Nairobi for further management because the patient was quite stable, was able to make the journey. This is the child.
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And as you can see, this is the entry wound where the bullet had entered. And
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now the issue here, of course, was to plan on the removal of this bullet and its visibility So, experience what Dan, this is the. initial extract was done and you can see the bullet had entered
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in that wound and to travel it down and lodged quite deep down there.
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What was there any discussion or consideration of leaving the bullet in place.
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Yeah, that's that's I'm going to come into
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that I'm going to come into that. So, this is where the bullet had the extra to show that bullet had that lodged quite deep and a city scan was done and the city scan was able to localize the bullet
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Now, we discussed the feasibility of living the bullets,
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and
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because it was quite a deep-seated bullet, and we discussed these possibilities of living this bullet And
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some cases we have left the bullet, especially if the patient is very stable and the.
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need to remove it. But
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with further investigations, some neurosagens said, why don't we try to see if we can remove the bullet? And
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I think the neurosagens who were already moving the bullet, you know, one that day. And then of course, you have to remember that when this happened, this was a situation where the
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political environment was very, very tense because the injury had occurred as a result of some political tensions in that area. And therefore, everybody was for we want this bullet removed. And
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why don't you people try to remove it? So we did some more investigations. And now this one, we did Anjo, and did you try to subtract your girlfriends were dead and The bullet was able to be found
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that it had not caused any damage to the vessels and again from there we was able to judge as to whether it was approachable and from that, as you can see from the trajectory If you look at this
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trajectory from where it had entered, it seemed as though it probably we could get it to it without necessarily getting it to any of the vessels What we did is we did more images, and in these
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images, we're just trying to find out the path which this bullet had had taken, and see whether from that, we can see from the entry and wait, it was as to whether it's possible to try to remove
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this bullet.
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Again, this was done by one of our very experienced you know, surgeons and they went in and from the images, they were able to sort of like see if they could feel the bullet. And because we did
40:16
have facilities for any further in trial localization, so and from that, they were able to dissect and actually follow the path of
40:19
that bullet, where it
40:48
had entered and get through the bullet and able to remove the bullet, as you can see, that's the bullet on that top left hand side. And very successfully, but this was a very experienced
41:02
neurosurgeon and the child did very well As I said, this was a case which was had a lot of.
41:11
uh politics involved and in fact and remember the mother had died so after this the child was actually adopted by what were very senior senior politicians and now he's he's he's doing very well and
41:27
and getting on with his life but going backward is there a discussion that a lot of these penetrating bullet injuries the bullet ends up really being sterile by the time it goes intercranially so the
41:40
whole discussion of leaving it behind can you just re-explore that yes we we in fact in fact which when when the patient comes when the patient comes with a bullet injuries
41:57
we manage these patients as by their clinical status so like there was another case which i wanted to present but because of table with this present where again. we left the bullet inside because the
42:13
bullet had entered and now we had to manage that vision for raising the clean up pressure and all that and the bullet had moved from one hemisphere to the next hemisphere and what we did is we managed
42:26
the patient for raising the pressure severity
42:31
and he recovered and after he recovered we did not go back and remove that bullet
42:39
Okay, can I make a comment here? In my setup which is in Ghana is also West Africa. What do we do when
42:51
we see that? I mean 20 years ago we might have adopted a different approach but what we do for the last year is to use the navigation system, the neural navigation and then ultrasound. We measure
43:03
exactly where the bullet is and if there is the possibility of doing any cartography where you can actually see that the anatomy that we have, and we measure and we see how deep it is, whether using
43:17
an ultrasound or the navigation system, we can decide to just leave it in and observe. And if with the position,
43:27
it comes out, then we might contemplate going in for it. But if it's that deep seated, we could just leave it and keep observing with time and do serial radiographic images and then you take a
43:40
decision. Thank you.
43:43
Professor Kava, how you've done a number of times, I'm sure, is your experience good?
43:52
All right, so it might set up, sometimes we get a bullet, a unique bullet, and sometimes most of the bullets are locally made.
44:03
So they are actually pills, they're data in multiples And we don't go up for all of them. Just last week we had one in the spine, and we took what we take and the rest. When we did the measurement,
44:14
we noticed most of them were not actually in the canal, but in the muscles, so we just leave them, and then we keep observing. And those in the brain, if it's accessible, we go in, but if it's
44:26
situated, we just calculate to look at how much will you damage? Is it in an eloquent area? What are the structures you're going to find? And sometimes, one thing I try to teach my residence is
44:39
not about technology. It's about common anatomy. Anatomy, we know how the brain is. We know the structures. Is it located? Then you complement it with technology, and you confirm it, and you
44:51
take a decision.
44:54
I think Dr. Kalba's points are very well taken. One of the primary reasons for extracting these penetrating missiles would be to reduce. risk of infection and the data isn't well actually there's
45:13
some data indicating that you may not reduce the risk of infection with an exploration and you run the risk of neurologic injury but I think the confounding factor in this case was that the missile
45:29
had penetrated the mother prior to entering the child so I'm wondering if that might have changed the dynamics and increased the risk for infection.
45:41
I do agree I think the purpose of this
45:45
joint collaborative effort is to look at before now and for
45:55
before 20 years ago I would have looked at this differently today one of the things that in Africa and sub-Saharan Africa specifically we should be looking at is maximizing the use of the ultrasound.
46:06
It's cheap, it's bedside, you don't need anything to complement to it, and it gives you so much information, and it helps a lot, and we use it almost every day, and it helps a lot to take a
46:18
decision. So for the future, we can look at it, and the proofs determine what it is, depending on the type of proof you use,
46:30
just that entrance in a hockey stick proof, you could.
46:35
Harry, Sam or do you have any comments on this, and going after you've had a number of many, many cases with gunshot wounds, well, how did you treat them any differently?
46:51
First, congratulations, Dr. Rongov for the case. It's
46:57
very realistic scenario, let's say I totally agree
47:03
with the political aspect and sometimes you are one of the indications that's not common in high-income country, you are simply forced to do some type of surgery for whatever reason, mostly in
47:16
unsung districts. It's a common thing and a few point just in a hurry that sometimes longer bullets have some part that's not blasted yet. So there is a risk. Sometimes we use the rubber-tipped
47:35
instrument while dealing with that because there is a risk of secondary blast inside the in the tip of bullet.
47:45
Sometimes we use the EVD or the upper end of the shunt to follow the track of the bullet just to trace the
47:54
track. Occipital injuries in general have a better outcome. Child have a better outcome if he survived the initial injury. Also for the positioning one, the horizontal. alignment. We actually
48:08
published a paper on that, that sometimes in a very similar example,
48:16
if we try strict positioning, the bullet would be time, the bullet would be time will settle back. I'm going to say I'm going to have to do something here. I'm going to mute everybody. Go ahead,
48:36
Sam, or I'm sorry. So if it's not vertical, if it's horizontal injury to the head in general, so sometimes we use the direct patient positioning, and with the time the bullet will go back to the
48:54
initial threat and just become more superficial and you can remove it just easy, but I totally understand sometimes we remove it, sometimes not. And which govern the immigration of the bullet. In
49:07
addition to the comment on the using ultrasound, I really appreciate that. The immigration may depend on the location because I think this type of penetrating usually stop when the bullet hits the
49:19
tinterium. In that example, you just show and if it's around the ventricle, if it's within the sabbatical space, this is a definite indication or a more probable indication to intervene or remove
49:34
the bullet because there is a high potential for migration. But I totally agree with the management of this case based on the circumstances mentioned and congratulations.
49:48
Thank you. Thank you, Mr. Grif. Harshu, you have some experience with this. Would you like to tell us about it?
49:55
Just in terms of the bullet, my experience suggests that if one doesn't need to explore on the basis of relief of Mass Effect from additional bleeding, then one can leave many bullets in without
50:14
adverse sequelae. In regard to Professor Nimms' case, I had an almost identical case in Kenya three weeks ago. Amazing that the patient was never intubated, never intubated And
50:31
the knife was withdrawn successfully after angiography showed no involvement of the vasculature. So different ways of handling it. I do have a very interesting case of a penetration, as from UC
50:48
Davis Sacramento, of a penetration of the brain along this same traverse from a nasal entry point to an occipital lodging of the barbed arrow of a longboat.
51:05
And, and geography showed the, the arrow lodged at the junction of the, the bifurcation of the internal credit order. And here the, we did a craniotomy at the simple region, so that we could
51:22
extract the arrow with its barbed tip in an antero grade fashion,
51:29
and not the retrograde fashion, which would have risked injury to the credit bifurcation had we withdrawn it
51:38
in a retrograde fashion. Thank you. Thank you. Professor Kava, you wanted to make some more comments. Yeah, I just want to ask the question.
51:48
When you have this impact of the bullet on the bone, do you sometimes have to do the cranioplasty immediately, or you leave it and do it?
51:59
At another time, depending on what you see and the possibility of infection, what is your protocol on that? Thank you. Good question. Yeah, the credit plus is done later on. We don't do the
52:12
credit plus just immediately. Okay. Do you do it immediately, Professor Kawa? Thank
52:21
you. Professor Kawa. Yeah, that's fine. No, we usually wait. At the beginning, we attempted some few and the results had not good. They come back with infection, you got to remove the clean
52:32
up, plus the material and it's a cost to the patient. Always less remember our health insurance system. It's not the same over there. Patient has to pay out of pocket and most of the time they
52:43
cannot afford. So you do the minimum and then you come back in a given time when you're running.
52:51
In section three and then you proceed with. Can I add something in this? is one important factor is the age of the patient. My experience in penetrating ganshot wounds comes from Mexico, not
53:08
because of people shooting at each other, but because of New Year's Eve, people shoot with the machine guns to the air. And every now and then, so frequently that has been forbidden for that
53:21
reason, the bullet will fall down and get into the very critical of a toddler. And I have seen four cases like that in five years. And it is an issue that the bullet that turns down in January 1st,
53:41
January 1st, there is an increase of penetrating wounds in toddlers on in two, three, four, four months old babies. And they get a brain in those kids, in those
53:58
baby is not as dense as the brain of a two years old and of course of a 15 years old. So it is possible sometimes to force the return of the bullet back to its track closer to the bone, to the place
54:18
of entry of the bone. So the age, what I'm saying, I mean each case is individual and each one does whatever they do the best of their understanding, their situation demands. But yes, often you
54:35
need to, I mean you have to consider the possibility that the wound migrates backwards if you force through the position because of the different density of the brain, the different level of
54:49
myelination of the brain, of a four-month-old, which is totally different And as I said, to a three, four, five, or one. at a 50-year-old. And because of that, because of the bone being so
55:04
thin, yes, we need to do the breathing of the wound, because we're asked that the bullet is not
55:13
infected by the heat, by the penetration or whatever, the scalp can cause some problem in the meninges as such So I think that age of the child is a factor. And if you happen to see a very, very
55:32
young child, unfortunately, victim of this event, considering the tracing part
55:40
of the wound closer of the of the bullet closer to the bone. But each surgeon does it individually. Thank you. I think, Sam, or you have a short question and we want to go on with the program
55:53
after that. Yeah, thank you. A short comment on that. Actually, we use
55:59
an account confirmation to Dr. Lazar of a point that we use. It's not a guideline. It's an experience that we use a role like a
56:12
defect less than 5 centimeter and less than five years of age. There is no potential. There is no indication for credit plus in the future because with the time the skull will go and with the time
56:25
the defect will be much and much smaller and will be less significant. I think this also can be considered related to the cranial clasty
56:40
in general. Thank you, Mr. Rada. It seems like I think we should go on just in a second here. Can you stop sharing screen, NIMM?
56:52
And just the case that you have of this young child What we see there is. And I could just imagine the mother trying to protect the child. It's just a tragedy. And you guys just did a fabulous job
57:05
and the discussion was just terrific. And these are all tragedy. So I
57:14
think maybe we should have Nancy give a talk. It's nine o'clock. We've already spent about 45 minutes. What do you think? Yeah, excellent. Great discussions Thank you, Professor Merengue for
57:27
that. Yeah, I think we should proceed with Dr. Epstein's presentation. Can we ask one question first? I forgot about this. Anybody else have a presentation that they wanted to make, please let
57:39
us know. If you do, we can either fit it in today or we can do it in the next meeting.
57:47
Dr. Simpson, you have a comment? No, anybody else? Okay. Okay, go ahead Excuse me, Jim, let's just remind everybody to - with their microphones on mute so that we can eliminate the extraneous
58:02
noises. Okay,
58:06
Nancy, you want to go ahead. This is, for those who joined late, Nancy has been a spine surgeon for 40 years. Her father was a spine surgeon in America. And
58:22
she's written extensively on spine problems as you know, she always says things the way they are. The spine industry doesn't like her too much because she's asking where are the controls, where are
58:35
the factual studies here, and I support that. So Nancy, she's a superb teacher. So Nancy, can you go ahead and give us a talk? Can everybody see my screen? Yes, I can read this. Okay. So,
58:51
you know, if people have comments, questions, you know, Justin, interrupt me I mean, the whole. of today, you know, Jim and I were talking about, you know, what to do with you and saying,
58:60
well, why don't we put together something on management of spinal fluid leaks? But as I thought about it, I mean, the most important thing is, especially in spine, is if you do the right
59:11
operation, you've got a good, you've got a good chance of avoiding them in the first place. And then, don't ignore them, manage them appropriately, diagnose them, and then appropriately treat
59:22
them.
59:24
This is an example of obviously a lumbar disc extruded sequestrator fragment that we're removing. This is a figurative diagram of what a CSF leak may look like. One of the references that I'm going
59:36
to give you later talks about the frequency of disc herniation. It was a study of over 4, 000 spine cases. Frequency of CSF leaks, 17 with the lumbar disc, higher with lumbar stenosis, usually
59:49
ossification of the ligament, very adherent to dura, or might be an ossified synovial cyst. well that's just clumsiness and ignorance on the part of the surgeon. But the other thing is also the
1:00:02
incidence of re-operations if you've had prior surgery the presence of scar obviously markedly increases the risk of a CSF leak. I'll emphasize throughout and I would ask our audience today I mean do
1:00:15
you just have access to loops and how many have access to microscopes and how many have access to the microscope that's sitting in the corner because that may be the access that they should actually
1:00:27
take the extra time to get out the microscope and avoid the incidence of CSF leaks. If they don't have a microscope loops are certainly the the preference right? Absolutely I mean the but the
1:00:40
biggest problem you run into is if the surgeon has loops but the assistant doesn't that assistant is not as readily going to be able to assist that surgeon during the operation itself much less to
1:00:51
repair the CSF leak. Anybody have any comments on that?
1:00:59
And why don't you go ahead, it's okay. That's one of the reasons actually why microscope is great because both of you can see what you're doing. I'm just gonna start off with, you know, a little
1:01:06
bit of the anatomy of the lumbar spine. You know, obviously we have the multiple vertebral bodies. We have the discs here on the right and on the left, it's when it's processes. You've got the
1:01:17
canal that's obviously in between. Let's not forget the anterior and posterior anterior ligaments as well as the yellow ligaments. And here you can see that's the posterior longitudinal ligament,
1:01:27
the anterior ligament you've already seen. It's semi-interspinous and super-spinous ligaments of the spine. You can look at things that are going to cause nerve root problems. Everybody forgets,
1:01:39
you know, you talk about generally lumbar stenosis. Don't forget about the unilateral lateral recessinosis that may complicate a disc operation. It might be a good reason not to just use that MRI
1:01:51
scan pre-operatively, but to get a non-contrast CT,
1:01:55
of how bad the prognosis may be. As Jim was saying, my father actually wasn't a resurgent. My uncle actually wasn't one of the first neuro radiologists, but here's one of his figures about drugs.
1:02:06
We're gonna use what we have to discuss with you as just as we do with the MRs and cats. But here's a new lateral and pertrophy facet. Here's some ossification of the olegment between the
1:02:19
hypertrophy facet, the ossification of the olegment. You get significant lateral recess stenosis Remember, you could also have a unilateral synovial cyst that actually may stay lateral or actually
1:02:29
go central. But don't forget the presence of stenosis as being a big factor in your designing what operation might be the best operation to use. Again, using adequate exposure is the most critical
1:02:42
decision that you're going to make other than the fact that you may want to choose the correct operation for the correct patient for the correct surgery surgical lumbar discs, degenerative discs,
1:02:55
prolapse discs, Those are not typically surgical lesions. We see papers all the time with people taking out black discs, where there's no neural compression on that MR and CT. Don't operate on
1:03:05
those disc. Those patients still need surgery. You're going to look at the extruded disc. Here you see figuratively the extruded disc. Extruded disc here on a sagittal MR. It's the disc that has
1:03:15
extruded through the fibers of the annulus, but are still in continuity with the disc space. The sequestrated disc, the one with the free fragments This is an example of the L45 level, a large
1:03:27
fragment that has herniated inferiorly. I can't emphasize enough how much neurosurgeons and the spinal surgeons need to be able to read their own MRF and CAT scans to localize where the disc
1:03:42
herniations happen to be. Not all discs are located at the disc space or just below the disc space. It could be lateral frontal, it could be way far lateral, it could be superiorly migrated, the
1:03:54
operation you're doing to deal with those cases.
1:03:59
Lateral disc can cause, again, lateral compression. Here's your typical disc herniation might be at the disc space, maybe inferiorly migrated and pinching on your inferiorly extruding nerve root.
1:04:09
However, put this superiorly. If you're pinning it superiorly next to the pedicle, you're getting the superior for terminal root. You're going to have to extend your operative decompression
1:04:20
superiorly, or you're going to miss that disc herniation entirely, and I'm just reviewing a medical legal case, as we speak, that exactly is discussing that. If this disc herniation is way out to
1:04:30
the side, you also have to adjust for that far lateral location of the disc. Here on your axial MR, you have a typical extruded disc herniation at the four or five level. And here on the sagittal
1:04:40
image, again, compression of the quarter-coinet compression of the nerve root, as well, ipsilaterally with that disc
1:04:50
Here's an operative image of your typical discectomy and. Remember, a lot of us will use intraoperative monitoring, EMG monitoring, SCP, MEP monitoring, depending on the location of where you
1:05:01
are, lumbar spine you're using, typically, SCPs and EMGs. Not bad to use your EMG probe. Where is that nerve root during the dissection? You sometimes don't see this nerve root until you've
1:05:14
actually taken out the biggest fragment to the disc. The nerve root may be splayed over the disc fragment. You don't want to make your incision into the nerve root and destroy that patient's
1:05:24
neurological function and give them a foot drop. The other thing is, I was recently in a meeting where everybody said, well, you do lumbar surgery. Well, it's old, you know, the foot. Does it
1:05:35
go up or down? Accenture, Halis, Dorsey, and plantar flexors. Everybody's forgetting about the femoral nerve. You know, L1, 2, L2, 3, L3, 4. You've got the L2 and L4 nerve roots that are
1:05:47
extruding at those levels. You may present patients who haveilius ous weakness, quadriceps weakness.
1:05:54
They may have a loss of the knee reflex and a sensory defects in the L2 to 4 distribution. And here is certainly the L4 distribution. Everybody's familiar with that. L2, 3 are gonna be over the
1:06:05
thigh. And here is an example up above of what the MR may look like. Here is 5, 1, 4, 5, 3, 4. And you can see the superiorly extruded disc fragment on your sagittal and parasagittal MRs. And
1:06:19
here on your axial study, your secret-strated disc is at the parapadicular level in that case.
1:06:27
Just the other day I saw a patient who, actually she was a friend, she happened to call, she said, you know, I have a real severe leg weakness. And I went to the local medical center and they
1:06:38
got a non-contrast CAT scan and they sent me home. And they said, if it gets worse than going in the emergency room, I said, well, give me permission to read your study I read the CAT scan, it
1:06:48
showed a massive, sequestrated, synovial cyst extrusion at the L3-4 level, almost filling the spinal canal. I told her, come right back, we've got to get a stanamor prior to the
1:07:02
MR. I asked her to lift up her leg. She hadiliosos
1:07:07
and quadriceps of weakness, severe. I also asked her, when was the last time, you know, you voided? And she said, well, I haven't urinated today because I didn't drink very much in the morning.
1:07:15
Well, we got the MR, it showed the massive synovial cyst extrusion and stenosis at 34 that was there on the CAT scan, but had actually been missed on the reading and also showed the massively
1:07:27
dilated bladder. Long story short, she went for surgery, she did have a bladder retention problem, postoperatively, ended up neurologically intact because she was operated on within six hours.
1:07:40
Again, you have to be able to recognize these things. The sciatic nerve, here's a classic example of an axial MR at the 51 level Here's your extruded disc herniation. Filling me. left side of the
1:07:52
spinal canal obliterating the S1 nerve root. Here's your thickle sac, well some compression not terrible, and you're right-sided S1 nerve root. Here we're working actually from the contralateral
1:08:03
side of the table to take out a right-sided disc herniation at the L5-DUS-S1 level.
1:08:12
We just stop from it. Does anybody have any questions for Nancy at this point?
1:08:17
She's going through some basic things for the younger neurosurgeons here and going to get into the repair CSF leak soon? Anybody have any questions they want to raise
1:08:31
for? Okay, I don't see anyone to play at Nancy, I'm sorry. Okay, no, great. L5 nerve root deficits, what's the best way to pick this up? Ask your patient to walk across the floor. Okay, you
1:08:41
can do 10 and gate testing at the same time. Ask them to walk in their heels. You can pick up that foot drop when you hear that sort of slide.
1:08:50
It's a much more effective way than just examining them than when they're sitting. Again, it
1:08:56
picks up a more subtle foot drop. You may or may not have a loss of the ankle response and then they'll have loss of sensation, maybe accompanying it, maybe not. Over the lateral calf and the
1:09:05
dorsum of the foot, the typical S1 nerve root problem. As they understand on their toes as they're walking down the hallway, can't do it on one side, that's your deficit. No ankle response and a
1:09:16
loss of pin of the lateral aspect of the foot endorcellate as well. The next point is compression of the corticoyna. Does the patient have a corticoyna syndrome? Everybody seems to forget about the
1:09:30
fact that patients can have a partial corticoyna syndrome, but it's as much of an emergency as the total corticoyna syndrome. They may have unilateral weakness. They may have unilateral sensory
1:09:40
loss. They may have sphincter dysfunction. They may have some sexual dysfunction I may have perineal numbness just on one side. But again, with these massive central disc herniation, you want to
1:09:52
know whether or not these patients have a partial quarter coin of syndrome just like you want to know. Do they have a total quarter coin of syndrome? But unfortunately, it might not be the
1:10:02
neurosurgeons or the spine surgeons, but the emergency room physicians, the hospitalists, our other colleagues, the nurses in the hospital, the PAs, the nurse practitioners. They don't
1:10:13
recognize that somebody may have a partial rather than this classic quarter coin of syndrome or they have a total paralysis, saddle anesthesia, urinary retention, bowel incontinence, sexual
1:10:23
dysfunction, et cetera. And here's your massive sequestrated disc and the urinary incontinence. Well, what are the surgical options? And really, when we're talking about spinal fluid leaks,
1:10:37
we're talking about surgeons often choosing the wrong surgical options, not having adequate access to removing the pathology at hand,
1:10:48
be it stenosis, be it synovial cyst, be it other. A unilateral laminotomy, great operation, but especially in a younger, healthier patient without any significant spondylotic disease. Extruded
1:10:60
sequestrated disc at that level or maybe just below. By the way, you're not going to find the superiorly extruded disc at the mid pedicle level. You're not going to find the foraminal disc or the
1:11:12
extra foraminal disc in this case with that kind of exposure But good operation if you have the right indication. Here is an extended laminotomy, we used to call itipsicontra, where you can look
1:11:24
for the disc herniation. You're doing some gentle retraction, but you may have a superior and inferior nerve root deficit in that patient. If you have a foraminal disc herniation or a far lateral
1:11:36
extrusion, here you have to far laterally take off a little bit of the lateral aspect of the set, remove the inter transfer serious ligament in fascia, and then expose the superiorly exiting nerve
1:11:48
root and the extrusion underneath it. But here you have medial as well as pherominal really far lateral exposure to make sure you are not sacrificing the nerve root just so that you can preserve that
1:12:02
pars into reticularis.
1:12:05
Unilateral hemilaminectomy, full fast-attectomy or foraminal and far lateral disc, this may be your best exposure. By the way, in your older patients who have significant spondylotic disease or a
1:12:17
spontaneous fusion at 51, you may not have to do any fusion in this case. And again, you superior foramidally exiting nerve root, your dorsal root ganglion, these patients may have exquisite pain
1:12:29
because of the dorsal root ganglion being compromised. And again, this gives you adequate exposure above and below. For those who are doing a far lateral disc, and they have never done one before,
1:12:39
I highly recommend using this exposure because otherwise you may damage the nerve root getting to where you have to go. And it allows you to remaining focused on where the pathology is. You can
1:12:52
follow that for amnole exiting nerve root, laterally, for amnole and for laterally. This will help
1:13:02
you avoid damaging or going right through that nerve root trying to take out the disc. I've seen too many cases of for lateral discs where the surgeon goes in, does the routine exposure and then
1:13:09
closes and leaves the entire disc behind. Oh, by the way, I've also seen cases where they do an incision, they go down to the subcutaneous tissue for maybe a sonometer, and then they close
1:13:19
claiming in this long operative note that they took out a lateral disc with phenomenal et cetera. I mean, it goes on forever. Remember, watch out. Some of these operative notes, very little
1:13:29
relationship to the operation that's been completed. Here -
1:13:35
Stop for a second here.
1:13:38
And you can see there's a tremendous amount of being written about. one, minimally invasive surgery, and two, even using endoscopic surgery.
1:13:51
How does that stand in regard to all of that entails more equipment, more expenses? What is the results in us doing the standard procedure that you've outlined here for many of these things is good
1:14:04
everywhere in the world and has excellent outcomes? Yeah, well, I'm also gonna get to that very shortly, but minimally invasive is minimally effective. I've done reviews of a lot of minimally
1:14:16
invasive cases. They don't have adequate exposure. They get not only the
1:14:22
CSF leaks, but they get neural injuries associated with it. Or they, for the spinal fluid leak, when we talk about closure, half the time they just close, they say, Oh, well, the blood clot's
1:14:32
gonna take care of it. And then they have a tremendous incidence of recurrent leaks. But I'm gonna get to that shortly, Jim, because it's a great question So I'm just going to finish the - coronal
1:14:43
hemilaminectomy, where you take off a half of the lamina above and below, it gives you bilateral exposure of the exiting nerve roots and the thegal sac, good access to a central disc herniation,
1:14:52
especially downbiting curates, which are like this. I assume everybody knows what a downbiting curate is like. Obviously, the old-fashioned lumbar laminectomy can be, in some instances, the best
1:15:05
operation you're going to do, because with horrendous stenosis, you basically have your spinous process coming right down. You've got maybe two to three millimeters at most of laminar on the other
1:15:15
side. If you use the laminectomy and remove the spinous process with angling your microscope, you actually can do your multilevel or single-level medial facetectomies,
1:15:29
really preserving the facets, avoiding doing effusion by using a laminectomy approach, as opposed to, many will go in and they'll just do bilateral full-facetectomies and create their iatrogenic
1:15:40
instability that then they have to go on to. So it's just something to remember and think about.
1:15:47
Minimally invasive discectomies, more CSF leaks, more other problems. Here are some of the references. We'll show you some references at the end of the talk today as well. Here's your metrics,
1:15:58
discectomy, coming down. And again, you know, you're going to have very limited exposure with these, getting these leaks. And I just recanted to hear, you know, you've got tubes, they may be
1:16:08
three to nine centimeters long They might be an attractive alternative, especially near more morbidly obese patients. But again, the ability to maneuver with these is markedly limited. 16 to
1:16:22
26 millimeter diameter. I mean, 25 millimeters is an inch. You don't have a lot of maneuverability in these cases. You're not going to get be able to put some of your instruments down. You're
1:16:34
certainly not going to be able to get a correct down there safely because you're not going to be able to get through the tube tube and around your neural structures adequately. So, Jim, to answer
1:16:43
your question, it markedly limits your ability to work in a 360 degree fashion. It markedly limits you because lots of times you come right down on the nerve tissue, you may be creating more
1:16:56
retraction injuries trying to do this. And again, you may be creating more CSF leaks because you don't have enough room to work around the nerve tissue, much less adequately extend your
1:17:08
decompression so you're fully decompressing the nerve tissue and allowing yourself to get in and around the nerve tissue to take out what your pathology is. A lot of the minimally invasive studies
1:17:20
show more post-op clots and infections, recurrent but very often residual or retained disc fragments, new neurological deficits because of retraction or the residual discs and sometimes just
1:17:32
frequent paralysis because of sometimes just going right through the quarter coin and major time CSF leaks. This is a study, European Journal of Spine 2015. The incidence of CSF leaks in over 4,
1:17:47
000 spinal surgery cases, 17 percent disc. This is what I mentioned at the very beginning of today's lecture, 36 percent with spinal stenosis, and a whopping near 15 percent revision rate with
1:18:01
previous operations. Here's an example of a patient who had a prior multilevel decompressive procedure for 5 to 51, massive recurrence CSF leak.
1:18:13
Again, if somebody goes in and does a minimally invasive operation, very few can make the mental and physical and appropriate adjustments to opening in that case or extending the procedure
1:18:25
sufficiently to bring in the microscope and actually do a formal repair of the dura. In other words, most of these CSF leaks occurred due to poor exposure. They're going to get more leaks and more
1:18:39
complex leaks. They're going to get more full field repairs. And in fact, in lots of instances in some medical legal cases, they obviously didn't do a repair at all. Again, the operative note
1:18:50
may have this multiple power graphs about, I did this, I did that. And there's no evidence that they actually physically with the bony exposure that you can document on a CAT scan could not
1:19:00
possibly get in the instruments that they claimed. You're going to have more post-op recurrent leaks and very importantly, more mobility, including more post-operative adhesive arachnoiditis,
1:19:11
postural hypertension, motor, sensory, reflex, sexual dysfunction. You name it, they have it. And actually on CAT scans, you can see the brain sagging. You can see journal enhancement and
1:19:23
other problems resulting from it. And again, this is what that leak may look like. So now we're getting finally to the CSF leak repair. I invite anybody to make any comments
1:19:37
We're going to go over briefly the anatomy of the meninges repair techniques using the microscope if available. That's certainly optimal betters
1:19:46
Especially because your assistant can then actually see what you're doing in help And intraoperative monitor
1:19:57
Hold for a second you're Nancy I
1:20:01
don't know where that noise. Let me find where that's coming from but anybody have any questions they want to ask It's my work. We've we've got about we started about 10 minutes after After 8 we've
1:20:15
got
1:20:18
Yeah, I guess raise my hand Go ahead
1:20:23
Professor comma, please do
1:20:27
Point about about all this is a low-income come trace depends on the kind of microscopy you use. We all don't have kind of 1-900 or pentetal. or whatever, you use the loops, and maybe you ask the
1:20:39
standard on hair. The big linkages can easily be seen. The question then comes with the small linkages, all right? Where in other centers,
1:20:52
probably if you get some kind of spy again, like for a second, you might be able to see it coming. You do vassala, not a word, but in your experience, what are the topical agents that you can
1:21:02
use applied to the juror that could actually help you in situations where the leakage is so small, you cannot actually switch it. Wow, I'm gonna get to that shortly because I'm gonna go over
1:21:13
different options. In instances like that, sometimes if you can't get a suture in, you can't get a drill stapling, you can take a small piece of a muscle patch graft and put that in and maybe
1:21:25
suture it to something else on the side, sometimes you can actually use
1:21:32
Derogen, or microfibular collagen, you can use abatine. I would caution against using gel foam and serge cell that gotta be removed because otherwise they're gonna cause compressive changes.
1:21:44
Different fiber and sealants can be used. Some you have to watch out. You don't wanna make it a thick layer because the thick layers can cause neurological deficits. But I would say number one, a
1:21:55
small piece of muscle from the patient and you take a hammer and you splay it out and you put it right over there and then you can put a small piece of onlay derogen And if you're really concerned
1:22:06
about it, you can actually, there's a kind of derogen that you can actually suture in place over that. And that in combination with the fibrin sealants can be very effective for treating those. Dr.
1:22:16
Kama, Professor Kama, what do you do?
1:22:20
All right, so we have my little experience in the last 20 years has to do with different agents, like she said, sometimes a little bit of muscle or fat. Is fat?
1:22:34
And then recently, about three years ago,
1:22:38
I found this material called Verissette TM. I think it's a genuine product, I'm not too sure, but Verissette. And it's so effective in sealing a small, small hose, you apply it and it just gets
1:22:51
bigger. Even when you are creating on intraventricular chemos, I use it, it's quite effective. And you don't have to, because when we try to switch out very small, tiny, I remember just last
1:23:03
week, we were doing a case, a spine case, and then we had a challenge. We
1:23:10
did a vaseva, we found out it was leaking, we put in fluorescent dye, we saw it coming, but it was so difficult to switch out. And when we applied it, it did work. But then I was kind of like,
1:23:22
okay, from my point, part of the world, maybe there are more novel items that you could use that would actually seal it topically. And I don't know. That is why I was just asking to know if there
1:23:35
are many more developments in that area. We all know that from the beginning, back in those days, we use the bone.
1:23:43
Yeah, I mean, it's a little fat, and we try to see them. But you can share your experience if you have any more than
1:23:53
items that you use. I know that in the 70s and the 80s,
1:23:59
Joe Ransall, who I trained with at NYU, at one point, he got a leak, and it was doing a pituitary, and it was a vascular leak, etc. He used crazy glue, but crazy glue is not supposed to be
1:24:09
used for this at all. Number two, fat is not a good product or tissue to use because it shrinks, it disappears and goes away. What was the other product that you mentioned? Because I was not
1:24:23
familiar with that
1:24:27
Yeah, I said very sad, V-A-R-I-S-D, very sad. When I said TM there's a different name. I think here. Yeah, I just got it like that when I had an opportunity for Suppression of the conjoined
1:24:45
train singer. We ordered and we got that and it's been very effective Is it like a durable repair or a durable alternative? I don't know about I don't know much about it And I wanted to know your
1:24:57
experience if it's been used
1:25:00
Well, I'm going to show you in great detail very shortly exactly what we use We may we may how much how long is in the next part take Nancy because we may have to Have you do that the next time?
1:25:14
Okay? Well, let's just try a few minutes of this. Okay, we all know the different layers of the Dura The repair technique first of all you have to admit that you have the leak you have to identify
1:25:25
it and repair it okay interrupted sutures, do not use a running suture. one running suture falls apart, the whole wound falls apart. Very important, if you have seven old gortec sutures, use it.
1:25:39
It's a non-resorbable suture. Do not use a neural wand. It unfurls, and it's a weaker closure. So gortec sutures, the needle is smaller than the suture itself, so it'll plug the needle hole.
1:25:51
And a neural wand, it just unfurls and it loosens. It's not good. Muscle patch graft with your interrupted sutures, it's the way to go, not your running sutures And the interrupted sutures are
1:26:03
the best way. And again, do not use fat. Fat reserves use a muscle patch graft. Here's an example of a repair. Here you're interrupted to dural sutures and in between them, if you have access to
1:26:16
it, micro dural staples, if you don't have them, just put in more sutures. And you may need to put a patch graft in addition to that. And what you do is, you just save your needles and then you
1:26:26
show them, so in the muscle patch graft, you're going to always want to check with your watertight closure with a valve salva. And here is after we've taken out, obviously a multi-level tumor.
1:26:36
And here are your dural sutures on either side. What you're gonna do is you're gonna flip them over and you're gonna put in your interrupted sutures here. And then you're gonna put your dural
1:26:46
staples. Everybody can see the dural staples that are in between here. What you do then on top of that, you just take one of your five-inch sealants. I would use the seal. It absorbs it over in
1:26:56
about a week Dural sealants or dural seal is approved, but it's been glommed and found to produce quadriplegia and paraplegia. So I don't know that I would go that way. You can use onlay derogen or
1:27:10
microfibular collagen. This is what I was speaking to Dr. Kaba back. You can take a small piece of this and put it just onlay over where your leak happens to be. You can then put two layers of
1:27:22
five-inch sealant on top of that Your alternative also to use a suitable derogen
1:27:28
on top of this. So here, your regular derogen - one layer of fibrin sealant, put your sutural derogen on top of that, and then put your fibrin sealant final layer on top of that as well. Here's
1:27:43
just an example of a minimally invasive laminotomy that was done. They refused to acknowledge the repair or in theory. They did a poor repair. They didn't open. They didn't do a more extensive
1:27:55
Boney D compression to adequately repair the leak. They ignored it postoperatively, despite the patient's postoperative intracranial hypotension and other symptoms and signs
1:28:04
of a CSF leak. They delayed doing an MR for months, and then basically it caused adhesive arachnoiditis that was the permanent irreversible deficit in this patient. Postoperatively recognizing
1:28:17
adhesive arachnoiditis, these are your normal axial MR scans of your lumbar spinal canal. And here, normal axial study, but clumped nerve roots.
1:28:30
Alternatively, is the empty sac sign where the nerve roots are clumped around the perimeter is what you may be seeing. Classically, you're going to want to repair these leaks doing your open
1:28:41
procedure to find out where the source happens to be. And remember, some of these might be real pseudo-miningosyles with nerve roots extruding into that sac. The best way to treat these CSF leaks
1:28:53
is avoid them in the first place with the correct operation And I'd notice them with the MR scan, you're not going to see anything with the CT studies, and then do the operation. Avoid the leaks
1:29:03
with good exposure. Give up the minimally invasive. Make your incision longer. Open the vertebral bodies as you need to. Use a microscope if you have access to it. Use the loops if you have that
1:29:13
Use seven or Gore tech sutures or non resorbable suture do not use neural on which is a monofilament suture that's going to unfurl and to that repair staples or much of past graft if you need it fiber
1:29:26
and sealant and the dirgens can be used. Diagnose a recurrent leak on an MR scan. Treat the leaks ASAP early and correctly repair the leaks. Basically, this is the premise. The early bird
1:29:40
diagnosis and repairs the CSF leaks early. You don't dawdle, you don't wait, you don't deny. And thank you. Okay, thank you very much Nancy, we appreciate it. I think we've almost, we've run
1:29:54
out of time here and Estrada,
1:29:58
maybe we should ask Sheila Bear, are you still there?
1:30:06
Sheila Bear to Shambadoy?
1:30:09
Well, yes, there you are. First of all, we defer to your tremendous experience. Any questions or comments or suggestions
1:30:23
from the meeting and what you've heard, what we should do in the future.
1:30:30
I think you're muted
1:30:34
Yes. Hello, do you hear me? Yes, we do. Okay, no, no, it's a good start, you know, I noticed that there are
1:30:44
40 people looking at them participating, and it's a good start and the important is to share the information to repeat the announcements And every day, maybe, when we before, and to prepare on the,
1:31:02
the, the course and share the course before the presentation. Yes, it's a good start, Jim. Yes, let's
1:31:11
go. Thank you very much. Anybody else would like to make some comments
1:31:16
You want to see if anybody else wants to do that. Professor, if you permit me.
1:31:27
There is an excellent book named Sayartika by.
1:31:32
by neurosurgeon from Tunisia. It is on the book review of SI. I reviewed it. It is highly recommended for the young neurosurgeon to look at that. It's a little bit expensive, but it is 1500 pages.
1:31:47
And I highly recommend they order it for the department. So the residents have access to that book. And it is online also. It's named Sayatika You can look at the book review on the SI. I highly
1:32:04
recommend, it's beautifully written. It's very vast. And I highly recommend that one. The other thing is that maybe Dr. Nancy can do one talk in future about corepectomy and anterior approach for
1:32:21
the disc removal, which is traditionally done. It has a lot of side effect And if any time she can make a lecture for that. So we can hear her opinion also, because it's a little bit controversial,
1:32:36
some neurosurgeons do it, but if you can arrange that for us, we appreciate it. Thank you for everybody for its participation. There's a button down in the bottom where you can check out. You can
1:32:48
just open it up and check off and leave us a comment on your reaction to the meeting We're going to, Professor Magwambi, any comments from you? We appreciate your preparation, your group did, and
1:33:01
the excellent discussion with any comments you'd like to make.
1:33:07
My only comment is possible to thank everybody who has participated, and then the other comment
1:33:15
on the attendance chat, the University of Nairobi, residents,
1:33:21
were represented and also from our colleagues from Africa, several were able to turn up. Let's advertise these meetings. As I said, I had to take the initiative to start the presentation, but now
1:33:36
probably this is the first and only presentation I'll be giving, because I'll have many of my other colleagues in the University of Nairobi who are very keen to present and they have a lot of very
1:33:48
interesting cases which they'll be presenting And then, of course, we would like to hear cases from other colleagues from Africa, and how they're handling the challenges which they face. Thank you.
1:34:02
Thank you very much Okay. Strata. Strata. Thank you for trying to really put in a major effort to get all this organized. We really appreciate it. Any comments or thoughts you have and what about
1:34:17
the next meeting No, I think this was, this was quite successful. And thanks, Dr. Macquamby and Dr. Epstein for your, for your presentations and I appreciate the active. participation that we
1:34:31
have from participants. We will convene the program committee to devise the program for the next meeting. For people who are on this call from Africa, if you have interest, please send me an email
1:34:50
or send Jim an email about potential topics for which you like to make presentations But I think we have a good start and I appreciate the participation of everyone. And Jim, again, thank you for
1:35:07
putting these all together in the first place. Okay, well, as Sam has as a fan of, and so does Professor Cabo. Yeah, Dr. Cabo. Dr. Dubel de Chambonos, wow, it's been a long time. I met you
1:35:24
in Brazil Yes, remember, yes.
1:35:29
we are close. Maybe you remember me in Portugal, in
1:35:34
2011, I don't even know how long
1:35:37
it was. By then you were in
1:35:45
France or something. That's great. Anyway, I was just going to make a comment on the previous speaker who spoke about the books. Sometimes in our part of the world is quite expensive to buy the
1:35:57
books and all that. But
1:36:01
if we have online versions, we can make them available and as institutions, we can easily subscribe or get our residence to
1:36:12
get some of them online. But buying the book is quite expensive and sometimes difficult to actually actually. So if you have any material, just let us know the link and then we can see how best we
1:36:22
can acquire to go deep into it. Thank you. Yes, the book is available online also. It's by the EM. company. It is online and you can apply for it. So all the residents can go through it and
1:36:37
it's really a beautiful and highly recommended, especially for the anatomy they have. Yes, it's described. It's beautiful.
1:36:47
All right. Well, okay. Always remember that everything on SI
1:36:54
is free. There are some books on there that are free If you look in the menu on SI, which is the journal, in SI digital, we've got over a hundred videos known, and she has at least seven of them,
1:37:05
which you can go in here in more detail, a little lectures that references there if you want to follow, and that's also free. So, and that has discussion. So, thank you all for coming, and
1:37:17
thank you everybody for participating. We appreciate the comments at the end I'm just reading here and thank you Ken.
1:37:27
Thank you so much Jim. Thank you so much. Thank you for organizing and moderating and thanks to colleagues. Thank you. Bye. Thank you very much. Bye bye. See you next time. Thank you Jim for
1:37:40
the major undertaking you've accomplished. Thank you very much. Thank you. Thank you Dr. Epstein for the lecture. It was interesting, honestly. Yeah. Thank you.
1:37:52
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