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Welcome to the 15th SNI and SNI Digital Baghdad Neurosurgery Online Meeting held on August 7th, 2022. The meeting originator and coordinator is Samir Haase from the Universities of Baghdad and
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Cincinnati.
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The lecture today is Advances in Functional Neurosurgery Deep Brain Stimulation for Chronic Low Back Pain. The lecturer is Ossoff Barrie Assistant Professor Director, Surgical Movement Disorders
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Program Comprehensive Pain Management Program, Surgical Neuromodulation and Brain Mapping Lab, UCLA Department of Neurosurgery, Los Angeles, California.
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The lecture is 16 minutes. The discussion is 16 minutes. There are 122 attendees from 18 countries. The video editors are
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Mustafa Isma'a from the College of Medicine at University of Baghdad and Fatima Ayad, fourth year medical student also from the University of Baghdad.
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So just the other day, I have a 14 year old son and he came to me and he said, Daddy, is University of Oxford? Is that the first university in the world? And I actually told him, No, it's not.
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Actually, the first university in the world is in Baghdad. And actually, Baghdad is a city that was built for academia from scratch. It's the only city that I know of that was built for academia.
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And Baghdad had a university when London was a village. Right? The world did not hear the word London when Baghdad was doing science. So I told this to him and it was, you know, he was surprised
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by this. So sometimes we have to reprogram our children because they hear things that are not accurate. So it's a great honor for me actually to be speaking to you on sharing some of my work. So
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I'm gonna talk a little bit about some work that I've been doing in functional neurosurgery that has to do with applying it for deep brain stimulation per chronic low back pain. These are just some
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disclosures.
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I have some NIH funding on this project, this first one. So Dr. Bull, Amir already went over a
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lot of
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this. In the United States, we have approval for certain forms of DBS, which are listed here. But there's a lot of other interesting areas we want to try to treat. Because as we all know, all of
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human psychiatric and function really comes from the brain. So if we can tap into the correct brain circuit in the right way, and it does as a big if, but if we can do that, then we can modulate
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these things. And these are areas that are under intense research throughout the world. And eventually we're going to look at enhancement of function. This is where humanity is headed and
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functional neurosurgery is going to be at the forefront of this. This was going to change humanity eventually.
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So all of these involve individual circuits. And we tend to focus a lot on the motor circuit because the motor circuit is easy to measure. It's a, you can measure it objectively. You can see a
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tremor going away. It's something that you can measure very clearly, but these other circuits are very difficult to measure, especially mood is very difficult to measure. because this is an
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internal state of the human being. And it's very hard to get a good measurement and accurate objective measurement of these things. So it makes it very difficult. It makes it more challenging. But
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today I'm gonna talk about why do we wanna develop therapies for pain? We know that this is very expensive to society and it's very common. So in fact, somebody told me that the most common reason
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anybody will see any physician in their life is for chronic low back pain. So everybody on this call at some point is going to experience back pain. And as we get older, that becomes worse. And so
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traditionally there have been different ways to treat back pain and pain in general. And today I'll focus on deep brain stimulation. We already know that spinal cord stimulation has been used for
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this in motor cord stimulation.
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And in terms of deep brain stimulation, these are the traditional targets. So the periacodactyl gray and the thalamus, these go back to the 60s and 70s And we know that the PAG is good for
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no-susception. and the VPN, which is the sensory thalamus, that's a better target for neuropathic pain. But although these have been used, they're not very good. On average, you get about 50
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chance of improving pain when you look at various series of patients. So there's variable efficacy, the randomized control data are lacking, and we don't understand the underlying mechanism of how
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this works.
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And now there's been a paradigm shift in neuromodulation for pain, and we think of pain as opposed to no-susception. So no-susception is the sensory phenomenon. The pain is subjective, and pain is
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the combination of sensation, cognition, and affect. And out of that comes this experience, which is a conscious experience of pain. So it involves multiple different circuits. And this is some
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work that was done at Northwestern University using functional MRI,
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Circuits that are involved in affect play a central role in chronic pain. So you can see here this is thermal pain and normal people involves the sensory pathways and thermal pain in chronic patients
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also involves sensory pathways. But when they experience spontaneous chronic pain, it involves these affective circuits that you see here. So this was our approach. We already know this as
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neurosurgeons. You can do anterior scingulotomy This is from Valentine. This is from decades ago that showed that you can go and do an ablation of the anterior scingulate. And these patients, they
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still feel the pain. They can still tell you that they feel the nociception, but they're not bothered by the pain anymore. So you're modulating affect in this case using a thermal lesion of this
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area. So we model pain as a combination of activity in neurons along these different dimensions So there's a cognitive dimension. is theologic dimension, affective dimension. And there's some
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combination of neuronal activity will lead to pain. And the role of neuromodulation is to push the neuronal activity away from this into a pain-free state.
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So multiple targets have been tried in the past. There's some listed here. There's some research that was done recently targeting the nucleus accumbens and the antiracinulate cortex. But all of
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these had some advantages and disadvantages And overall, there were limitations of these trials. So first of all, they didn't include a very homogeneous population. Many of these trials are taking
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people with all kinds of pain. There's a disproportionate focus on central pain, which tends to be very difficult to treat. Lack of blinding, there's hardware limitations, and lack of
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patient-specific optimization. So our hypothesis was that we were going to use area 25 as a target.
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Also known as CG-25 is located here. It's a subgenuine cingulate cortex. And a lot of research has been done on this target that shows that when patients are depressed, that this is a hotspot in
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the brain. And if you do deep brain stimulation to this area and patients respond, this is in responders that had major depression and they had improvement in symptoms. You can see that the hotspot
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becomes a cold spot. And so there's been a lot of research done on this area And people that the some researchers in my lab use trichography to show that this area is connected has high connectivity
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to the prefrontal cortex, the ventral striatum and the anterior cingulate. So we hypothesized that deep brain stimulation in this affective circuit should be able to improve symptoms of chronic low
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back pain. So our paradigm shift is that pain is a brain state. It is not a spinal cord state It is not a peripheral nurse state. It is a brain state.
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you have to go into the brain. And so we at that time, Abbott was the only manufacturer of these segmented leads. So you can see traditional deep brain stimulation uses a cylindrical lead, whereas
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segmented leads allows you to direct the current in specific directions. And so this was our lead of
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choice. We went with the Abbott system because they were the first ones that had directional steering. And this would allow us to capture the firm fibers that are necessary to treat pain. And this
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is the study design. So the patients get implanted. And in the first six months, we are, this is non-blinded and we obtain the optimized settings for each patient. So each patient has their own
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optimal settings that we discover And then these are used as either the active or shamp. So when we go to active versus sham, double blinded crossover design, the active patients will get their
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optimized settings and the sham patients will get the sham settings. And then after three months, they cross over to the opposite arm. So if you're active, then you go to sham. So this is a
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blinded withdrawal design. And then once we're done, we will then unblind the patients and we'll look at the trichography and we'll try to optimize patients based on the imaging So this was a design
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we went to the NIH to get funding for this and we received funding to do this in initial set of 15 patients. So we have we're happy to announce that we have done our first patient recently earlier
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this year. And in this patient, this was a 68 year old patient. And this patient had low back pain, eight out of 10 He had a history of prior low back surgery and failed spinal cord stimulation.
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And there was no preoperative.
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spinal pathology on imaging. He did have a history of cardiovascular disease, but no family history of psychiatric or cardiac disease and all history of drug abuse. So this patient was a good
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candidate. We did a trichography to identify the best target for this patient in this subgenial cinellate region, using one of our protocols. And then based on this target, we took the patient to
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the operating room for deep brain stimulation. And we use a standard setup So in our hospital, we use this alarm. This is the metronic arm for intraoperative imaging. This is again, we use a
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Lexel frame as well to do our placement. This is just to show you that at one of our other hospitals, we use this frame, which is called a, this is made by FHC. This frame is a custom 3D printed
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frame that allows us to do the surgery under more comfortable positions and conditions because this is not attached to the - bed. So the patient is allowed to move their head during surgery and also
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you can do simultaneously both sides of the brain. So this is the position in the operating room and this is what it looks like with the microelectro recordings. And again, we are doing this
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operational wake and the patient is able to do some tasks in the operating room during the surgery, as you can see here
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And then once we are happy with the location, then we secure the lead in this fashion to the skull. And this is the postoperative imaging showing the location of the electrodes in this patient. So
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we're targeting the bilateral sun genial singulate as shown here. So this patient had no surgical complications. He was discharged in two days and then he came back for follow-up programming in
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three weeks. And at approximately one month, he had an improvement in pain to five out of 10 He was actually a gym instructor and he was able to work out after one year. he had not done any workout
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because of his pain and he was trying to work out and it was getting significant improvement from the stimulation. And so this was our first subject that we had implanted. So I wanna also briefly
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show you what we do in the operating room. So our lab is very interested in studying human emotion and reward and affect. And the way we do this is that because we're doing our surgeries awake, you
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can see in the slide that we're able to while we're recording from the brain, we can have the patients do certain tasks. So this is a temporal discounting task. And the patient is being asked some
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questions about choice between selecting a small amount of money in the present versus a large amount of money in the future. So we're trying to understand how these areas of the brain influence our
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choice. And again, the patients are awake, as you can see here, this is a patient awake in the operating room. doing these various tasks and answering these questions. And so here's the task
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design. So in this task, the patient reads this question and they answer this question while we record from the amygdala and from the medial organ or frontal cortex. Two areas that we know are
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important in choosing various tasks and human subjects. And recently, and this actually was being done in epilepsy patients So you can see here that these patients are undergoing placement of depth
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electrodes to localize seizures. And so we have electrodes located in the limbic system, including the amygdala and the medial OFC as shown here. And at the end of the electrodes, we have micro
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wires. So we can get single unit neuronal recordings from these areas. And you can see that the medial orbital frontal cortex is significantly involved in choosing immediate versus delayed rewards
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So when
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the patient was choosing the immediate reward. We saw single unit activity in the medial orbital frontal cortex. And we also looked at the difficulty of the choice. So when the choice was easy
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versus when the choice was hard. And under the easy choice conditions, again, we had higher activity in the medial orbital frontal cortex, telling us that this area of the brain has something to
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do with monetary choices that we make. So I just wanted to briefly talk about one other technology that we're using in the United States, which is MRI-guided focused ultrasound that Dr. Volamir
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mentioned earlier. So this is a technology that is incisionless. There's no surgery involved in this. There's no implants. So this is a special helmet. Inside this helmet, there's 1, 000
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transducers that send out ultrasound waves. And we can focus this on a single point. And at that single point, you can make a thermal ablation. So you can burn that spot instead of having So the
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advantage here is that unlike radiation, as we know radiation takes several months before you get an effect, with this you get an effect immediately. So you can make some adjustments in the patient
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while the patient is awake to fine tune the location of the lesion. So we start by doing a full head shave here. Again, we have to apply a special frame. This is a CRW frame that we apply under
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local anesthetic. We shave the head completely. Once the patient's head is shaved, then the patient is locked into the helmet, as shown here. A special cooling cap is placed and water is
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circulated over the scalp. And then we do the sonications with MRI guidance. And you can see this is
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MR thermometry. The MR thermometry is showing us the temperature of the lesion. And so we can start at low temperatures, such as 44 or 45 degrees Celsius. And at this temperature, you will not
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get a permanent effect. It will only last for a few minutes And so you can do live adjustments. until you're satisfied with the location. And once you're satisfied with the location, we go to the
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medium temperatures to confirm. And once we confirm, we go to the high temperature to solidify and make it a permanent lesion. And that lesion will be about the size of a piece, so about three
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millimeters cubed. And you can see this is my notes from a recent case. We did a total of 12 sonications in this patient. And we are gradually increasing the power and gradually increasing the
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temperature So at these temperatures, we're making a permanent lesion. Once we have confirmed that location, you can see here he's getting good relief of tremor by the time we're at the 11th
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sonication. So this takes about one hour, and then the patient goes home immediately after the procedure. And this was the same patient. This was before, this is a patient with essential tremor.
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You can see pretty severe tremor prior to the procedure. You can't even draw a straight line. And this is immediately at the end of the procedure So you can see that there's a 90, greater than 90
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improvement in the trimmer here. in this patient. And this is what the lesion looks like on the next on post-op day one. We get an MRI and you can see the lesion located in the fallamus here
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showing us that this is a good lesion and we have stayed outside of the internal capsule to avoid any complications. And just a few other things that we're doing, we are also implanting Utah arrays
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in the motor cortex and the Pridal area This is a collaboration with Caltech and this is being used in patients with
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tetraplegia to try to restore function in these patients. So we're decoding activity in the motor cortex and in the lateral inner Pridal area. And you can see this patient has no ability to use his
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hands or legs, but by decoding these signals, he's able to play this game just using the brain signals. And so that's one area that we're doing some research on. And also my laboratory is working
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on designing new electrodes to use an epilepsy. So currently, as you know, with depth electrodes, you have to put in 10 or 20 electrodes in the brain. And these wires are coming outside of the
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patient's skull. And then they have to be attached physically to a recording system, which is very cumbersome. So we're working with the bioengineers and electrical engineers to design electrodes
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that are wireless. And we can keep these inside the scalp. And then potentially in the future, we can send the patient's home and keep recording from them for over several weeks. Currently, we're
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limited to recording in the hospital for about one to two weeks, but that's not adequate. Sometimes people don't have any seizures in one to two weeks. With this technology, we should be able to
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send the patient home for one to two months. Once we're satisfied with the data, we can bring them back and then do the definitive operation. So that's just a small sample of what we're doing at
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our center here. And again, I'm happy to take any questions inviting
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you. That was amazing. That was amazing. Yeah, I would, I would hear a feedback from Dr. I have a on the term here. But first I would like to thank you. Dr. Dr. Barry, that's very eye
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opening. And yeah, it's, it's very nice, especially for the media, the frontal cortex Because we are working on Jara Seimed, Jara Sracta Seimed, Toma
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and effects. And we know that this area is not very well understood. And seeing that, oh, you are working on this on a therapeutic level. This means that, oh, this is a great work. And yeah,
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you think the student and this resident can appreciate this And I think that summarizes the meeting
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that. We have the, what we have in Iraq on the current basis. And this is just some ideas also. So for people trying to think of functional neurosagerie, here's the, I think that's a nice demo
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and combination. Thank you again, Dr. Bari. And Dr. Hebe, if you have any comments, Dr. O'Neill, it's up to
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you. Dr. Hebe, would you like to make any comments? Yes.
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Thank you so much.
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Dr. Bari, please, you
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are talking about this high-fore technology.
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What about expensive? Is it expensive such like DBS or visioning? It's easier for that. Visioning also, minimally invasive process. We have the - we can't do it as minimally invasive basics but
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how far is the knife less?
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So is there a big difference between them and the cost for the patient - Yeah, for in fact, for the patient, it's very similar cost. In fact, I think for the patient, it's cheaper because the
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patient, I know this because a few patients want to pay cash for this procedure. Otherwise, I wouldn't know the answer to this, but if you compare the cost for the surgery, that includes the cost
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of the anesthesia and the post-operative care. This is only the procedure. So it is a much cheaper procedure if you look at the cost, but again, I think just like in Iraq, both of the deep brain
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stimulation and focused ultrasound are covered by Medicare. So it's very little out of pocket cost for the patient here in the United States. And I think generally my feeling is that I think deep
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brain stimulation is better in some ways because you can treat both sides of the body.
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And it's reversible and you can modulate it, right? Whereas with focused ultrasound, it's a lesion and you cannot change it afterwards. So in general, for young, healthy patients, I recommend
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deep brain stimulation. But if the patient is too old for surgery or too sick for surgery, or they are philosophically against the idea of surgery, then I recommend focused ultrasound. But we're
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not able to do focused ultrasound on both sides of the brain. As you know, if you do a lesion of the thalamus on both sides, then there's a very high, much higher risk of the patient developing
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speech difficulty and balance difficulty - Yeah, yeah. It's amazing to go also for brain gaze theory and writing this station of brain, the machine interface. So you are doing this with a full
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team of what technology
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Actually, I can't imagine how you are happy to start this work. It's a neuro-reconstructed. So what's the team containing? Yeah, so for the brain machine interface team, includes the Caltech
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neuroscientists. So that's Dr. Richard Anderson's lab at Caltech. In this postdocs, they do all of the scientific work And then the surgical team is myself here at UCLA. We perform the operation.
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And then after the surgery and after the patient recovers, then Dr. Anderson's team at Caltech then either goes to the patient's home or brings the patient to the lab. And they do their studies in
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the lab with the patient.
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Also, if I think one thing - correct me if I'm wrong - But what you're doing is. either unique or done with your, by very few people around the world. Is that correct -
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Yeah, for some of the things that we do, yes - Yeah, and so
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if people, I don't want people to feel, if you go to most centers in this country in the United States, will most centers be doing this work -
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No - No, and that's what I think they should know This is, and the reason you're doing it, and I'll tell you because you can't answer this, is because you're a creative and innovative scientist,
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and you're making use of all the resources at your disposal, and trying to solve complex problems, which there are very few centers in the world that where you can do that. And so I think it
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represents to the young people here, a vision of the future, and what you can do and what you can accomplish.
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It's the same as we saw earlier this morning. It takes bright people who are innovative and creative, who have the vision to wanna pursue their dreams, to be able to make them come to reality.
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And
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we respect what you have accomplished. It's going to be like some of the other things for the world leading -
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I think the point is anybody can do this I think with the setup you already described that you have there, you can already do this. This is not
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rocket science. I think that if I can do it, anybody can do this -
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Yeah, yeah, that's very good. And
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I wanted to ask you a question if I could, so
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the key to your back pain, every back pain is probably the most pain the most common symptom that people present to. physicians within it. As you mentioned, everybody gets back pain at least
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sometime in their life. The major problem is patient selection.
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That's correct. That's actually the biggest challenge that we have. In Russia, for example, there is nothing like Workman's compensation insurance for those who don't know that as people get paid
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if they come in with pain and they get in the United States and they may be able to get off work. People have found over time that that can be an incentive not to work. In
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your group, it would seem the greatest challenge is, and I noticed the patient you picked, had virtually no concerns. I didn't see anything about Workman's compensation or anything, but it's
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patient selection has got to be critical Well, I think when we applied for approval from our government agency, which is called the FDA year, They actually, if you want to use a device for a new
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purpose, like an existing device for a new purpose, you have to get a special kind of license from the government called an IDE. So you apply for that. And when we applied for this, one of the
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first things they said was that you need to exclude patients on Workman's Comp, which is something I did not think that was a good point - Interesting Okay, terrific. Thank you very much. Sounder,
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we've had just a terrific session. You want to - I just want to add one other thing. I think that for any other students or faculty that are
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interested in visiting our center, we'd be more than happy to have you come and visit us. We've had many people visit us from many countries. So I think in the beginning, we were still learning
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how to do that. But now we're pretty, we have a smooth system in place. And anybody's always welcome to come and spend some time with us so that we can learn from you more than you can learn from
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us -
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Very good. I wonder if we can ask Jorge and if ask if anybody has any comments about the meeting and we could have some final comments by Jorge and Dr. Cohen, sorry, in yourself - Yeah, I
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consider that we have that it's already Monday in Baghdad.
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I mean, I summarize with the, and I still OSAF's
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the spirit on what is just said that we, when we receive visitors, will learn from them more than they learn from us. at an equal level as they learn from us. And today's conference show that. No,
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I mean, we show the innovative and creative way of thinking. And also showing that the problems are universal. The ideas that Osafo, Dr. Bari has resonate in Baghdad and the ideas that people in
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Badan have resonate here in the United States as well So I cannot be anything but proud of having been part of this first conversation. And also show something, nothing like personal conversation
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because we may have seen that paper by Dr. Munir Farah, somewhere there in something, googling something. But it's not that the same when you're talking to him and he's guiding you through the
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paper, through the difficulties and is not that the same, Dr. Barry or Dr. Abdul Amir to reading their papers as in this engaging in data conversation. So I congratulate you all and
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also fantastic synthesis. We learn from them as much as they learn from us, no? And thank you. I am, I say a big thank you to the 46 that are present, 45 without me, that are present still in
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this conversation Thank you -
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Ali, your country of birth is Persia and Iran, your neighbors to Iraq, throughout history, you had a conflicting relationship and tell us what your thoughts
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are - Dr. Azman, with what has happened because during the sudden and the war, there was no problem with Iran and Iraq. a guarantee you. Everybody visited because they have a few very important
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Muslims sharing one in Najaf who is the king of the Muslim mola, the paritad and the carpalad, the son of him. So there was no problem. Always, there had been good relation. But
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the expresidence, Saddam, the start of war and all the problem. Even now, almost 2 million Iraqi were living in Iraq because I came out because of the war. And there was no problem because the
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originally, the old old Persian, Iraq and Iran, they were all one country and the Afghan estan. Then the British government started to divide all of it So we have to blame it on the British people
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to do that. But there is no problem because really culturally, we are all the same and the same language. different language, but same cultural background. And I'm so thankful to Dr. Hoss to
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arrange this thing, this conference, really what you have in creating because we have to share the information with the young generation. And I really commend you, Professor Osman, to have such a
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great vision to opening the wall for the neurosurgery and the young people who wants to join and also to share the opinion I really appreciate all of you -
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Okay, Shamer - Thank you.
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Thank you, Dr. Barry, for the comments. I think for the student that's very, very interesting. And definitely we'll have a method to collaborate. And I think after your comments about Dr. Heba
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presentation and your presentation, And now we have the answer for the why. Dr. Osman and Dr. Lazarov said, just let's have
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Dr. Bury. Let's have Dr. Bury. Now we have this and we are thankful for that.
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I don't know if Dr. Munir is here or if you have a final comment and or we can then ask this question - Thank you very much, Dr. Laz. You did appreciate your invitation It's really a good
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opportunity to show our efforts to the rest of the world. And from the Dr. Bury presentation, actually several ideas will be issued. I hope to have your contact address - Chair, several ideas and
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DBS, actually the first DBS done by me in 2009. I
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distill the major work of the D-Bury instimilation is still in our center in Iraq And thank you for your very nice. presentation. Thank you. Thank you.
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And definitely you will try to connect the
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especially with Dr. Bari. And if the student have any question, I think there is also student from Aura from
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UCLA. What's your opinion today just to close with these a few comments from the student? Because that's also important.
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So Aura, do you have things in mind? What's your appreciation? Or how do you find this for you as a student - It was amazing to be here today. Honestly, a little overwhelming with all the
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information that I am receiving, but it's great that I'm just able to be here and learn from so many amazing individuals who are doing a lot of good work.
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go ahead and hard work in this field. And I'm really excited to continue to learn and to just have such amazing mentors in my life. So thank you - Thank you.
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Akkam, do you have a comment?
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And please present to you, Akk, and to introduce yourself - Yeah, first of all, thank you to all the professors, to all the speakers today, it was very inspirational Akkam Osama, I'm a fresh
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graduate from Akdadarak. I've given some presentations for cases in previous SI meetings,
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but today was something next level. If I may say so, the presentations were very inspiring. I think we learned a lot about neurosurgery and
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innovation from the USA, but at the same time from our country So that was very - special moment for us I think. So thanks to all the speakers.
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Yeah, that was, do you mind if I ask one question from Dr. Heba, why do they have such a high number of Parkinson's? Because they did study in California that the pair areas which were given
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their poisons for the pesticides, those country people, they were all affected with Parkinson's. This is one study I know. So maybe somebody should look at the thing because it's a very high
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number of Parkinson's. That's according to Dr. Heba. Maybe somebody to look at that one to see what is the reason they have so much the neurologically sold over there because of some exposure to
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some chemicals or something.
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Actually, as you know, Dr. Parkinson's disease, it's something related to the the Paminergic Close. And all we are dealing with now are primary. Parkinson's, so it's primary cause at the close.
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So it's Parkinson's per se, about the cause of Parkinson's disease. A little are familial, but the majority are idiopatic. We are happy to look for the cause and we will -
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Thank you - Thank you. I think that's something to think of Maybe there's a comment, there is Alcother. Alcother is a Iraqi medical student now studying in I think, Uzbekistan.
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Also with us from - Azerbaijan - Azerbaijan, sorry, I'm sorry. So yeah, introduce yourself and if you have any comment, thank you - Hello professors, doctors and students. I am Alcother, 50
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medical students at Azerbaijan Medical University. Actually, I think this meeting was like a time machine because we started from the history of Neurasej or Naira, which is the past. And then we
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discussed everything about the future, the instruments, the researchers and the audience, the ideas. It's actually greatness in three hours. So thank you, thank you for everything - And thank
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you for participation for all, and you
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will have new comments We can collaborate also in the next meeting. I think that this is a take extra time maybe because it's the first time setting in this setting, but I think each talk, each
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presentation deserve to have its time and have this discussion. And yeah, what I have in mind now, I'm thankful for everybody for spending that time with us. And yeah, I hope we will collaborate
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in the future for next. We are definitely open for suggestions about the design of next meetings and the direction and even for speakers, if you have anything in mind that you can put on the next
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meetings, we are more than happy to do that. So I will,
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for the program and from my side, I will leave the mic to Dr. Osman to conclude. And thank you - Good to do, Summer - Thank you very much, Summer. It's one o'clock in the morning. And we thank
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you all for coming. And hopefully you can give Sam or some feedback on what you thought about this. And I've already seen a number of the comments and we appreciate it. Sam or we just did a
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wonderful job. Thank you very much - Thank you - Thank you, Summer - Thank you for everyone. And yeah, see you next month maybe.
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of the best and thank you Dr. Bari for being diagnosed. Thank you Dr. Munir Kamas for being against today and thank you Dr. Heba Dremir. Thank you so much. Thank you so much. Bye bye. Thank
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you. Thank you. Thank you.
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