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Welcome to the 15th SNI and SNI Digital Baghdad Neurosurgery Online Meeting, August 7, 2022.
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The meeting originator and coordinator is Sammar Haas, universities of Baghdad and Cincinnati
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The program and speakers are Professor A. Hadi al-Khalili, former chair of the Department of Neurosurgery, Baghdad University.
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He is speaking on Highlights of Neurosurgical History in Iraq.
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The next speaker is Monir K. Faraj, Department of Neurosurgery, College of Medicine, University of Baghdad, Baghdad, Iraq. The topic is a new, simple, cost-effective, neuro-navigation system
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for neurosurgery. New ergonomic instruments for surgeons. The next speaker is Heba al-Dulamir, neurosurgeon, trainer, Arabic board of neurosurgery From Dr. Saad al-Wittri, Neurosciences
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Hospital in Baghdad, Iraq.
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Speaking on, establishing a world-class functional neurosurgery program in a low to middle-income country. The next speaker is Ossoff Barrie, Assistant Professor, UCLA Department of Neurosurgery,
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Los Angeles, California, United States of America This topic is Advances in Functional Neurosurgery Stereotactic Treatment of Failed Chronic Low
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The speaker is Professor A. Hadi al-Khalili, former chair of the Department of Neurosurgery at Baghdad University. His topic is Highlights of Neurosurgical History in Iraq
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So my talk is very simple. It is about highlights of neurosurgical history in Iraq
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and what has been done over the past decades. In fact, we are honored to have the history of modern neurosurgery linked to Iraq, where Sir Victor Horsley, who
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is the founder of modern neurosurgery, just prior to Harvey Cushing, who is the real founder of modern neurosurgery. He was buried in Iraq. He came with the British Army in 1916.
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And then few weeks later, he suffered from heat stroke And then he was comatose for two days, and then he died and buried in Amara, which is in the just south of Baghdad. Here in Amara, there is
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the war cemetery. And that is the names of all the people who are buried there. And you can see that the bridge over Tigris has been bent nearly 90 degrees to avoid going through the cemetery. So
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that's the plaque here that I'm standing beside it as in 1981, which I look a bit younger.
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Professor Najib Yakubi, he was the founder of neurosurgery in the past. He started the neurosurgery in the '50s and he trained in Europe and then he established and started the neurosurgery hospital
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impact lab in 1960. His main interest
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was Wainz-Lakotomi of psychosurgery and he did trauma and some other surgical procedures. And then we have Markoam Parhart. He's an Assyrian from the north of Iraq. He graduated from Edinburgh
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University and trained in Stockholm with Oliver Corona and then back to Iraq. And then his main interest was final surgery and he died in 1960.
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He lived by three eminent physicians here in the United States. The professor after the result was the third in line and he was graduated from Baghdad University in '48, trained in US. in NYU in
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1960 to '65 and back to Iraq '65 and '67. Well, I was honored to have been one of his students when we were medical students in the fifth year when we studied neurosurgery. And then he was back to
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New York in 1967 and remained in NYU as a faculty and then went to private practice.
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The real founder of modern neurosurgery, of course, is Professor Saadwitri, who graduated in '56 from Baghdad Medicals, and went to London in '58 and then '62 of RCS and a '65 return to Iraq to
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start his task of building up the neurosurgical practice in the country. I graduated '66 and in '71 to UK, trained as I said in Germany and Switzerland, Canada and '76 back and have added to my
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professional work, I had some interest in research which I had
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implemented and did some research work in Iraq. In the '90s or early '90s, a total of 12 qualified neurosurgeons were running the show in Iraq and most of them were qualified with RCS from UK, but
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one colleague he came from Germany and Berlin, he was at his training and the other one qualified from France.
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Neurosurgical Services in 1950s started at Baghdad Medical School Teaching Hospital under the auspices of leadership of Professor Yachubi. And then in 1960, as I said before, specialized hospital
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started in Iraq only for neurosurgery and nothing else. And then 1990, there was a surgical specialty hospital related linked to the medical school and had about 20 stories, 20 floors, and each
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special, some specialty has a floor. There's no general medicine, no general surgery, no OBGYN, only special surgical lines. In 2002,
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Dr. Saadil with Renewal Sciences Hospital affiliated with Ministry of Health was established and they are running a great show there with science and the upgrading of the services. A number of
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neurosurgeons in Iraq in 1999, total was 48 neurosurgeon, worked in 12 neurosurgeon centers. At that time, population of Iraq was 27 million. So we had one neurosurgeon serving nearly half a
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million population at that time. And when I was in England in the mid-70s, the rate was, again, same thing One neurosurgeon to half a million population at that time.
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Diagnostic facilities available before we had the CT scan in 1978 was very simple, but plain x-ray, myelography using myo deal with all its complications and the problems, but we didn't have
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anything else. We have air encephalography as a means of diagnosing and geography using direct carotid puncture and the technician brain scan, that's all we had at that time. Then in 1978, two CT
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scans were installed one in the neurosurgical hospital and the other in the university teaching hospital and back that.
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Surgical procedures were done
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in all the centers. In fact, they did almost everything.
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Trauma, neuroplasm, infection, abscesses, and everything else. But something peculiar to Iraq is high data cysts, which is called by one of our professor, the professor had energy as cancer of
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Iraq, because it's really very dangerous if you don't deal with it properly. And this is a solitary cyst here, behaving like space occupying lesions, very silent, until it becomes progressive in
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size and then produces neurological problems, or it can be multiple. And in which case, treatment is really impossible to secure the patient. In this case, when the solitary, it's not structured,
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you can remove it at the patient is. really safe and the cured.
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Neurosurgical training in the country start after 1980, there was no scholarship because of the war in Iraq, the Iraq-Iran war, and then we had Iraq-1991 war, and all the problems. So nobody can
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go abroad to get more training. So training was basically by apprenticeship, but in 1986, an Iraqi board of medical specialists specialties was established. And that covers the major medical
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specialties, but in 1989, the Iraqi board of neurosurgery was established.
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And to get into the Iraqi neurosurgery board, you have to be a graduate of Iraqi medical school or any recognized other medical school, which was not the case at that time because of the
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difficulties in the country. So nobody will come from outside Iraq. And then you have to complete one year of internship. And then you pass qualifying tests before you be accepted to train in the
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neurosurgical board.
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To get the neurosurgical certification of the Iraqi board, you have to have five years of training and rotation with the pediatric and adult neurosurgical submitting research project. And you have
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to have a mentor for that project and you have to defend it in front of a committee And then pass written and oral exams. And then you will be qualified neurosurgeon.
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There is another means of getting certification. That's the Arab board of medical specialties, which is based in Damascus, Syria. And established in 1978, it covers again major specialties, but
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in 1998 started neurosurgical board, but not in Iraq, and Iraq started 2007.
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We had before, well, 2000, after and before micro-neural surgery. We had the brain navigator, a brain lab. And we have brain endoscopy. In fact, before we had brain endoscopy, we used to use
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the pediatric cystoscope to get biopsy from the brain tumors, in case it's required.
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And 2004,
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of course, until 2022, the current year, we have great advancement by our colleagues in Iraq in general. And Dr. Munir, I hope you will touch on that in details later on.
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Research, we had the clinical research, while experimental research, we had some innovations as well. Clinical research, as I said, this is mandatory for any students of the Iraqi board to have
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projects of research.
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and that will be part of his requirement. And we have many individual and joint projects and different topics on clinical problems in neurosurgery, including abscesses and tumors and everything else.
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Experimental, we had some projects on the cranial nerve dysgeneration because it was found that third nerve can regenerate, but in different ways, the nerve fibers will go differently and have
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different function. So we did a good project on that, but unfortunately, there was some problem at the end. Then we had spinal cord grafting in mice, and we proved that spinal cord grafting can
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be done. We used the sciatic nerve for grafting, hemichordotomy area. And it was published in the spine in
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JRL. in Edinburgh and then we have proceeded to dogs. And then with dogs, we had implemented the Surinar graft, added to it a momentum and force biometric graft. Some research on biofeedback,
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but at one time there was treatment of epilepsy when you can take the EEG of the patient and then analyze it and get the alpha waves of the patient to make him hear his alpha waves supposedly to
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reduce the resistant type of epilepsy. Pidotid cyst of the brain and orbit did a lot of experimentation on that with the glove filled with water and sacs. And then did CT scan to see the changes and
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the density of the CT scan to differentiate it from tumor. Innovation, we had some scale for setting sunshine just to quantitate.
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setting sun sign and then instruments for high diet based on this kid's game and there's some simple sign to test the power of coordination and
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proprioception and of thalmoscopy made easy by very very simple way but you can't have medical student maybe in five minutes they will be able to see the funders and then have
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to know about what's going on in the funders. Very simple way of doing it.
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A current number of neurosurgeons more than 200 neurosurgeons including around 10 female neurosurgeons and over 100 residents now in Iraq and more than 20 neurosurgical centers with a new technology
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available in most of them. Population of Iraq around 40 million and now it is one in neurosurgeons serving 200, 000 and. population. So the torch was passed to our younger colleagues, younger
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leaders to take over, and we are proud of their leadership achievements and progress. And thank you.
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If you have any comment, Dr. Osman, Dr. Lazarev, Dr. Ossoff, and Dr. Ali Khansari. If you don't mind, I say something to share with our other young colleagues. When Dr. Khalili talked
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about Dr. Victor Horsley, it is in the history of the neurosurgery, the first epilepsy surgery done in 1884, while Dr. Horsley was on the 12-year-old young boy who was kicked on the bed with a
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donkey, and he had damaged his brain at a constant seizure, and he operated even at that time 1884.
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to remove the score and the pichine recovered. It is written in the British Journal of the Medicine. I saw the original one which we had it in our library at UCLA. I would like to ask a
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question for
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Dr. Achelevi just to have the full picture because most of the people, I think they don't know about it Like literally we have a strong career in Iraq building a department and teaching people,
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treating patients. But at the end of his Iraq time, there is a huge event, I think change a lot. And yeah, this is part of the story And I would like Dr to just Khalil. inform and form.
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everybody about the event, about his kidnapping and what happened because I think this is part of the picture and part of the story. Yeah, but life in Iraq was difficult really for everybody before
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2003 and after with the sanction and the lack of everything the budget or
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the salary of the doctor was 3 a month So he has to live with that and we have lack of papers, we have lack of shuns, we have lack of oxygen, many operation lists were canceled because we don't
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have oxygen. We don't have any air conditioning in the theater. So you have the sweat you possibly use maybe two liters, literally of sweat during six hours of surgery. So you have to feed
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yourself with lots of water. So it was difficult time at that time again then
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2003, I had a problem, but I was, my car was
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taken by force, by three people with two guns with each, with the hands of each one of them, and then I was going to really to be shot at that time. So they took the car from my driveway and then
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I went inside and they shot out the door, one bullet, but fortunately the door was thick, so nothing happened, but they took the car. But they were a more important event to happen in 2004 when I
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was kidnapped. Kidnapped, I think, because I created a big society in Iraq called Iraq
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Rescue, culture and development, and
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environment and culture rescue society with many distinguished Iraqi people from all six of the society. So I was the president of that society. I think that created a lot of fuss in Iraq at that
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time. So I was kidnapped then and put in the trunk of the car with handcuffs and blindfolded. And then I was taken somewhere outside somewhere back that locked in and then they wanted half a million
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ransom, half a million dollar.
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And then about, we just more three, more than three days I was released, but they accepted 30, 000 dollars. I was a little upset because they realized that I'm not worth half a million, I just
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That is what this is.
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So, I was released then. At that time, I was not really in distress at all. First, maybe few seconds, few moments, I was distressed and I accepted the reality and that's it. And once the
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kidnapper was beside me, it asked him to take a picture for me with his phone. So, he took a picture and said, That's no good. Put the handcuffs and blindfold and take a picture. And then I
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smiled at the phone.
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But of course, he did not send me that picture because he would be the expose himself. So, after that, I stayed in Iraq, but they asked me to leave the country and then I stayed just for a few
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months. And they asked me to leave the country, not to stay at all. That's why from 2004 until now, it did not go to Iraq. I always, you may know that I was offered to be the Minister of Health,
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the Minister of Higher Education a few times, lately and two years ago. But I apologize because I thought
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from here rather than to be a minister in Iraq. I was here in Washington as a cultural attachit, dealing with the link of Iraqi health and
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higher education with American institutions and they have lots of activities. I have a big conference at the Library of Congress and the video of that conference about five hours. You can see it at
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the website of the Library of Congress and then now I gathered about 300 Iraqi American academics leading professors in the country with
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Professor Peter Agri, the Nobel Prize winners, to attend that meeting. And for three days, we had two days. We had a big conference
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here at the National Post by the National Academies of Sciences and created a project called Together for Iraq with 43 committees in each branch of life, of science. 18 divided medicine, and the
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rest in education, and law, and everything. And link to Iraqi committees, but unfortunately, that did not materialize and did not work because of the situation in Iraq. So many things happened
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and we are here
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trying to help Iraq in whatever way we can.
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Bless you, you're just so wonderful, wonderful things you're doing, and we appreciate it But to Dr. Talili and this mostly for the students, when we say cyst, and we look at the cyst, like a
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big ball, balloon, blood on the tiktazcan, to operate an idiotic cyst is like a
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disarm and atomic bomb, because if the cyst explodes, all the
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idiotic content within the cyst, they spread over, no? So it's quite an. technical and surgical achievement to operate on, I thought it ceased of the size that Professor Kalili showed, you know.
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And I agree with the statements or that Dr. Roseman said about the research as well, know the relevance of the research. And the final statement is an admirable work and commitment to your country
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that you're going to do in Dr. Kalili, you know. Thank you, thank you so much
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Dr. Kalili, I thought you had a very interesting presentation. You have, the history is very interesting in Iraq. And
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it again supports the fact that there are bright people everywhere in the world who have created
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many, many great things. You mentioned about experimenting with spinal cord transaction and
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and
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so forth, were you able to see some forms of recovery and those experiments? Yes, indeed. It was after we finished with the mice, we proceeded with middle animals, the dog, and then it was a
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project for a PhD student, a vet doctor,
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and we used, and as I said, in mice, we used the
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sciatic nerve for the mouse, and we had definite histological recovery and hypertrophy of the axons going through the gap, but for the dogs, we used a sora nerve, and then we had four groups of
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dogs, one sora nerve minced craft, we used minced craft sciatic nerve in both experiments, missed the nerve graft. So you missed the floral nerve graft as group one. group two as a control group
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three as minced graft with pedicle of omentum coming through subcutaneously, coming to the spine and switch out with the dura and the fourth one only omental graft. And then we, with the third
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group that's both sewer nerve, minced graft and omental, we have almost full recovery of the paraplegia. And we have video for that But the video, you know, at the time of sanction, everything
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was difficult. And the video does not show exactly the color of before when the child, the dog has complete hemiplegia, coparaclegia,
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and the recovery, complete recovery, the video pictures, they don't show the same color. So I was skeptical because people made out that, but it is truly full recovery of the paraplegia this
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group with minced chural crap.
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and supplemented by a mental graft. A mental graft, we got the idea from one of our professors in south of Farrac and Basra, Dr. Hammersian Sadie, the late Hammersian Sadie. Again, he was an
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innovative surgeon. He was to go for the prostate through the perinium. So he used this one telegraph for treatment of elephantiasis He brings the momentum under all the
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ligaments going to the thigh, and then the elephantiasis improved significantly. So I have
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the video with me here for these dogs, and she got her PhD with distinction, the girl. But unfortunately, she was killed with her daughter. And this mess, what we had in Iraq, it was very,
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very sad for me, me personally for Iraq in general.
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That's excellent, excellent work. And when was that done? It was done and
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we started 2002,
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extended
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2005. It's a traumatic work. We published some articles in surgical neurology and international by Dr. Kennevaro who was doing similar work in a little with different techniques and mice and dogs
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and then a monkeys in which he was experimenting with can you restore spinal cord function after a transaction and they were able to show that you can just as you did. Were you able to publish that
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work or that this young woman did with you? No, unfortunately, well they have the thesis with me here
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Well, if we could watch, we could see the video. Uh, if, um, it's up to Sam or, but the other thing I would suggest is, if you want, we can publish the video or even your short summary of
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this experiments. I would have a good to publish them in surgical neurology international. I think it's very important for the literature to know this. Uh, Dr. Canavaro with his work has
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undergone enormous criticism because people don't believe it, but I can tell you the experiments were done in multiple laboratories around the world, and it is outstanding work. And the work you're
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doing is very interesting. There was a doctor in the United States by the name of Harry Goldstein who used your momentum. You probably know the name. We corresponded with him, by the way. Yes.
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And, and he was also underwent tremendous criticism. Uh, he was a general surgeon. but he used the momentum on the spinal cord in the brain to revascularize it because of just what you said. It
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has, as in the leg, it has huge vascularity and amazing absorption powers in the tissue for proteins and fluid and so forth. So you were ahead of your time. And I think you could even write a,
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either a small short editorial or a letter to the editor with your video, we'll publish them. And I think she will get credit. And I'm very sad to hear that she's not alive, but you will be able
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to give her credit for what she has done. It's very important work. I love that, especially for her. I had the fact the idea of using the momentum for treatment of idiopathic intracranial pressure
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at one time, but I did not, they would do that. Well, it's very, very creative, very good The next thing you said. was that you were, I thought I understood that you were
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doing experiments with cysts in the brain. And did you use, put balloons in the brain to do that to measure their effects? How did you do that?
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We did, that's at the beginning of the CTISCOM fact was in 1978 or '79. I have got a surgical look left, filtered with water and then amputated the thumb to make it a smaller sack and then one of
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the other fingers to have a bigger sack and I put one in the orbit with some slices of fat in the orbit to simulate the orbital fat. And then one sack was put in the cranium itself and then the CT
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scan for that cranium and see the density because in the orbit, there's something peculiar
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It is interpreted by the CT scan as brain as tumor, a solid tumor because of the physics problem of transition from bone to fat, is that immediate transition so it will the computer will be confused.
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So, many times I opened the cranium just to go to the from the roof of the orbit to get to the tumor in the orbit and then at disappointed to see just it is the sack filled with fluid That's why I
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did this experimentation and then proved that orbital the cyst in the orbit has five to seven times more dense than cyst anywhere in the body Very interesting. Yeah, because of the location in the
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orbit born all around fat inside complete discrepancy between the density of the two there's nothing in between no no soft tissue just bone and then fat. So the computer and interpret that as a tumor.
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And it was published, in fact, in American Journal of Competrized Radiology. And it's a very interesting observation.
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We received over the years many papers on intercranial hemorrhaging. You knew the subject well about people in various countries taking a group of patients with intercranial hemorrhage and removing
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them
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and reporting their success. What bothered me, and you know about the randomized studies that were done in England, which have some very serious flaws but remain the major standard papers in the
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world. There's some additional papers that it didn't make any different information. And to me it was always a very reasonable idea And you could do this with a balloon tip catheter. to put a
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catheter in the, say, the frontal lobe, a blow up the balloon, and you could measure this in many different ways. You can put contrast in the balloon, for example. And you can see what would
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happen if you left a balloon for 30 minutes or 60 minutes or three hours or 24 hours and then deflated it, what would be the recovery of the animal? And it would at least give a standard approach to
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testing some of the principles in hematoma surgery, one of which is that the surgery should be sooner. And it would prove that.
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The other things that complicate an acranial hematoma, the fact that there are chemicals related to the blood in the brain itself, which causes inflammation and other things. But there are, just
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like you're a very creative experiment with a glove. This is something that can be done simply anywhere in the world. You don't need anything fancy. And you can find a standard answer to probably
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one of the major health problems in the world. And maybe some of the students around this can think about that or talk to some of the neurosurgeons. But there are, just as shown today, there are
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examples of diseases we see everywhere that bright people anywhere in the world can find solutions for a new present at them. You see, at the time, Anne, we didn't have any equipment, literally.
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What
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we have, they needed repair. We don't have spare parts. So once I was operating on acoustic neuroma, and just worried about the patient, so we don't have any sense that anything to dictate, to
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discover where the patient is. So my colleague, neurophysiology, colleague, we brought a pin, ordinary pin, and connected it to wire, thin wire. And then we use that as a probe to stimulate
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the nerve and find out if there is any reaction there contraction. And it didn't work all right at that time.
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I think as a student, let me just say one more thing. I think the students should listen because from your presentation and the presentation which follows you on the technology, it shows that you
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don't have to be think that you cannot make great achievements because you can't do the same things as people in countries with lots of money.
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It doesn't take money, it takes brains, it takes creativity, it takes determination, none of which you can buy with money. Absolutely right. Actually, I would argue that the money actually
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inhibits innovation, because you realize it's spoils people because they just throw money at it and try to solve the problem. I think you're right. All the same when you have only one set of
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clothes and you have to go twice with the same people, you actually articulate all the possibilities, a different tie or tend to tie up in two of those things, absolutely. I agree with you also.
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Money sometimes blocks the creativity, yeah. As you can tell, surgical neurology is interested in supporting creative and innovative people anywhere in the world. Well, Dr. Kavili, while Sam is
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getting that up, And I'd like to invite you to be on them.
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member of the Board of Surgical Neurology, International, and SI Digital. We need people with your experience in judgment and wisdom, and it would be a true honor for us to have that happen. Well,
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it would be my honor, sir. It would be my honor. I'll correspond with you once I get the summer to give me your address, but you should be
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praised everywhere in the world
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for what you've done. The speaker is Monir K. Faraj, Department of Neurosurgery, College of Medicine, University of Baghdad, Baghdad, Iraq.
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The topic is a new, simple, cost-effective, neuro-navigation system for neurosurgery new ergonomic instruments for surgeons
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I have the honor to introduce Dr. Munir Kamas Varej. He's an eminent Iraq in neurosurgeon. He's a practicing now in Iraq. He's the president of Arabic board of neurosurgery, the Iraq Center. And
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actually, his teacher, he's a leader in neurosurgery in Iraq. He's one, I think he's the one or two of the main leader on the current neurosurgery in Iraq And what I want to say before starting
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the presentation, that something very peculiar about Dr. Munir, he has support, like he's a really supportive person. And
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I think everybody knows how much he spent from his pocket money for every project to make it perfect That's very. interesting that's very different and I think for the young generation that's a very
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very important thing. Actually we are proud of that. So Dr. Munir, you can share the screen and you can start the talk and you are more than one. Okay. Thank you very much Dr. Samir and thank
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you very much to Mr. James Osman at my spiritual priority for giving us to make some two presentations each one about 12 minutes. This represent our last issued papers. I will start with, can you
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hear me? Yes. Okay. With this an in symbol cost effective navigation system we name it an easy navigator for neurosurgical interventions. As you all know, the navigation techniques was primarily
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designed in order to reach a deeply seated tumors that cannot visualize easily after opening the bone in cranietomies. Traditionally, we have two main types, either electro-magnetic or an infra-red,
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which is more commonly used now. Both of these systems depends on registration or all known. Can you share the full screen? Yeah, please. Okay, now, as you all know, the navigation techniques
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was primarily designed in order to reach a deeply seated
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tumors that
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cannot
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visualize easily after opening
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the bone in cranietomies. Traditionally, we have two main types, either electro-magnetic or an infra-red, which is more commonly used now. Both of these systems depends on registration of the
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position of the head in the space during the surgery by using, for example, fiducials, or by using laser pointer and the register V, shape of the head through these infrared cameras and make a
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fusion of the image with the MRI of the same patient.
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In 2007, actually, we faced with a problem that no more brain navigators were available in Iraq, as the contracts of the
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maintenance ended, and we don't have such an opportunity to work on them again. We started to think out of the box We try to make a new navigation by using a free software, it's available on the
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internets, called the 3D slicer, with a computer or mouse.
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How this process is done? Actually, we take the MRI sequences of the patient with the special orders that are coronal axial, sagittal, 1 millimeter thickness, secure image with no overlap or no
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tilt. and then put this into the software 3D slicer in order to get this 3D image of the brain tissue which is one of a one. It is the real size of the patient. After which we decide, we study
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this 3D shape and decide the entry point from where we should pass to be the safest and the nearest point towards the deeply cited tumor. Then we put a draw another point at the service of the tumor
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and another point just less than one CM outside the cerebral cortex and connect between all these three points in order to get a trajectory. And I will come in details for this
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During surgery, we do the craniotomy. We take this. It is just like the lecture presenter, put it on this slide in the trail, opening the air mass and try to point the same entry point that we
43:22
just mentioned in the 3D model of the real patient. Then we try to elevate this air mass through the trailing, just few millimeters away and then we rotate the whole trail until we adopt the
43:44
position of the trail to be the same position of the trajectory that we made on the 3D model of the patient, after which we will fix it by Leila Detractor or any fixator and then we start to do the
44:01
surgery along the trajectory reaching to the mass. Now, how we did that work? It took from us about one and a half year. We started with building a 3D-printing model of an actual patient, and we
44:21
tried to do the surgeries on these 3D models. I will show you this 3-minute video to explain what I just said.
44:38
Can you hear the voice or not?
44:41
Yes, no, no, okay, the voice of you is not there.
44:48
If you want to comment on it. Okay, this is just a model of a natural size brain tumor patient. At the beginning, we decided where the entry point should be
45:04
The technician with me will try to rotate the 3D model on the screen to be just like the position of the patient inside the surgery Thank you.
45:26
Then we use this presenter with air mass facility
45:35
And we try to, this is fixed by Layla Detractor on that side. We take it on,
45:43
we try be as close as possible to the entry point and ask the technician to register this entry point into the 3D model of the patient
46:08
By moving the air mouse within an area of 1C and diameter only, the movement will be accurate. If you go more than one centimeter, the calculations will be wrong. That's why it's very important to
46:23
localize the entry point
46:33
Then, the technician will try to draw a line from the
46:41
cerebral cortex into eight points toward the service of the tumor and measure the distance in millimeters and draw another point just less than one CM outside the cerebral cortex so that we will have
46:59
a well calculated trajectory.
47:06
Then we will go back
47:10
with the air mass at the entry point
47:17
then we try to pull it a few millimeters up
47:23
and then we start to rotate the whole tray with the air mass until we reach to the this point and the whole
47:35
trajectory will be enlightened which means we are on the same trajectory
47:48
Then, we fix it with cell, and
47:54
then we will have this trajectory will operate apart, and the same line
48:04
On the next stage, I had the opportunity to have something called Mediant Navigator. It's a new Canadian company, and actually this is the company that manufactured the
48:21
infrared cameras for the all navigators all over the world, even for
48:26
brain lab and for metronics Soon they decided they manufactured their own navigators, they call it Mediant, which means navigation EMT because they started the EMT surgery. So I decided with them
48:42
to cooperate and we operated upon,
48:46
we used for all those 10 patients, our navigation method, and after you determine the trajectory, we put the indicator for this conventional navigator and compare the
49:01
trajectory, especially measuring the distance from the surface of the cortex toward the surface of the tumor. And in these 10 cases, we noticed that the variation in the variant is more accurate
49:18
than us, definitely, but the variation between their measurement and our measurement is just between plus minus 2 millimeters. We use it by using this cobile, calibrated this cobile to measure
49:33
from the cerebral cortex toward the surface of the tumor. After these 10 cases, we decided to work on our own, and we operated upon four cases, and we measured the actual distance from the
49:48
cerebral cortex toward the tumor, and compare it with what we have done in the computer, and we have the same result. It was right between a plus minus two millimeters.
50:04
But is it a perfect method? No, it is not a perfect. It's still there are certain limitations. The most important one is that in this method, we are, we depends on the shape of the cell side and
50:18
the gyroide, till now. That's why we can not use this method, this method, for example, with a Berhal biopsy because I need to have a cranial to me and to see the cell side and gyroide In
50:33
conclusion, it is a simple method. It costs nothing. It is just a
50:42
computer with an air mass
50:46
and that's it. And it even does not, with the well-trained head, it will not cost you more than four minutes in order to do it. It basically depends on the air mass which is a Bluetooth technology
50:60
is neither an elicatromagnetic wave nor an infrared. That's why it is simple, economic and cost nothing. Actually, this has been published in the world in your procedure, it will be in the
51:16
printed version. In the next August 22 and even a patent registration will be issued next week in Iraq for it. Thank you very much, this is my first one
51:32
Before I start this new trends in designing micro-surgical instruments, I would like to make a few simple presentation about
51:43
the surgical laboratory. This surgical laboratory was established by cell funding. It is not governmental, it's by us in the neuroscience hospital which have been recently renamed as SAD and WITRI
51:57
hospital We were able to by two microscopes and these eyes volunteered to bring us another third one. These microscopes we train our board students. They should have at least three training courses
52:19
in trajectory, intermediate and advanced on chicken pie and on a living mouse and then on a 3D models before they participate in the final examination of the Arab board. We also had all the learning
52:38
the projects of the upsurgeon, the 3D-printing models which have been recently issued, especially in the corona pandemic, in order to provide the training to the students as if there is a cadaver
52:51
and this represents the third training course for our board students. Tell me we have a 3D-printing and we had a lot of
53:05
patents and research papers recorded by using this 3D printing technology. Many papers have been issued and many patents have been registered from this lab and even we have the digital library which
53:17
is now has more than a 25
53:21
terabyte of lectures and books in neurosciences
53:27
My topic will be what are micro-organization
53:32
and easy and actually there are no such words in English language if you look for in the dictionary. From where this micro-organism is came. We all know ergonomic it means that we design everything
53:49
we use according to the shape and measurement of the human body and this approach have been widely used in 1980s. We see the special microscope chair with a hand rest and even, for example, Sogita
54:07
with a hand rest have been developed in order to reduce the trauma of
54:14
the neurosurgeon, even the mouth piece of the microscope in order to rotate it. It's all related to aerodynamic. But must surgical instrument have been designed, actually, in order to utilize it
54:32
for the target tissue, for what they have to do. But unfortunately, we notice that a lot of them will not accosting to the surgeon's hand configuration.
54:47
In order to design any surgical instrument there are certain principles. I have summarized, for example, these instruments either primary, that's to say this is a direct tool. that will direct in
55:02
touch with the human tissue or secondary tool, which will handle another instrument in order to put it in the human tissue, like the needle holder or an urismo, a clip applicator. Another
55:16
principle that most of our surgery work depends on vision coherence. In another way, this is a hand-eye
55:26
coordination But still, we have something we call hearing coherence. We,
55:33
just like the one who is playing the piano, in manufacturing or designing surgical instruments, sometimes the hearing is important. For example, when we try to design an hierarchical motor drill,
55:48
we have to design it so that the sound will be different while dealing on different bone, for example, the cortex or the deploy of the bone. In our practice, we all know that while we are
56:01
concentrating on, for example, posterior faucet tumor, our ear is always concentrating on the sound of the pulse in order to check if there is anything will happen at one of the any cities, even
56:14
before he noticed that. Another principle I call tunnel concept, and this tunnel concept is that we are allowed to put anything we want, any modification, inside a cylinder, inside the tunnel,
56:32
as long as these utilities will not affect the outer service of the instrument which will be in touch with the human tissue. Now we come, what are the problems that we may face with these
56:48
instruments, and I will have an example of the classical needle holder They all know
56:57
the problem of lung instruments. right with a pen on it, a right board, you will have a good writing. But if you use a long one, your tremor will be propagated. And that's why the instrument
57:10
probably to be designed so that the tip of the target, of the instrument will be near to the tip of your fingers. Now, most of the surgical work actually is a supination And the during supination,
57:28
if you put a piece of clay and do the supination, you will notice that the deepest part on the supination will be in the hypofhener MNS. And what does it mean? It does mean that this strongest part
57:44
of your hand during supination is in the hypofhener MNS. If you are using the Myohager needle holder, the classical needle holder, you can see that your hand the needle holder with a very long
57:59
distance from the tip, that's why the tremor will be more propagated, and you are very far from the fulcrum, the most powerful part of the hand. And that's why with dealing suturing, with a tough
58:13
tissue, it is difficult to use this classical needle holder unless you modify your grip to be like this in order to make the inferior handle much closer to the hypofinar
58:26
MNS, ideally you have much more power to handle the tough tissue.
58:35
This depends actually on what is called the third lever physics law where the effort is close to the phallochrome, the load will be less than if we close, if we make the effort far from the
58:50
phallochrome, which is the hypofinar MNS. It is just a single physics.
58:57
Another concept, beside the micro-organism, we call it penisiation. We know that the most difficult work of the hand is writing, and that's why we need several years in order to master this. But
59:12
at the
59:17
same time, the most beautiful, the most intelligent instrument we created actually is the pen Why? Because you have 36 degrees of control on this instrument by your hand. That's why we had another
59:35
concept we call it penisiation. And penisiation we mean we try to convert most of our surgical instruments to make it just like a pen so that we have 36 degree control over it From these two ideas,
59:55
we had. designed what we call pen needle holder. We converted the conventional needle holder into something just like a pen with two cylinders. This is a 3D print of it. Till now we couldn't
1:00:11
manufacture it in a rack yet. It has a box joint to hold the two jaws with an op to locate. And these two cylinders connected with this sibling in order to elongate or to shorten the length of this
1:00:29
needle holder. The jaw also has a sharp edge of the distal end. This is a scissor. So that the surgeon can make the knot and he can cut this string without any of his assistant, which will be much
1:00:46
quicker, especially in deep, small, narrow spaces We have this, as you see, this is a groove of an x shape. I will come to you in a while we did this.
1:00:59
You know that the needle grid, basically we have a free type of needle grid, how to fix the needle into the needle harder. We have this, what we call, set right needle grid. By this, we use it
1:01:12
when the wound to perpendicular is the actually
1:01:15
surgeon position. When we tilt the needle
1:01:22
24 degree toward the tip, we call it oblique needle grid. And we use it usually when we have the wound and parallel to the surgeon. But when you change rotate the whole plane of the needle toward
1:01:36
the tip, this is called rotated needle grid. And it has no use in surgery. But when you combine this rotated with the oblique, we call it combined rotated and oblique This is especially made the
1:01:53
legume used.
1:01:56
indeed, narrow spaces for handling sutureing from the proximal to the distal. And when you incline it toward the shaft, it will be a combined use for sutureing from the distal toward the proximal
1:02:11
margin. This group will facilitate the position of these needle herders into these two combined grips.
1:02:23
Now, the third concept, easy, what is the easy? It's an elicatronics integrated with surgical instruments concepts. For example, we are now working on this project. You all know the bra reactor,
1:02:38
which may create a pressure over the brain tissue while you are working on a deeply seated masses, for example, and between religions. And then most of the time we forget it, because we are
1:02:51
dealing with something else and we end with infarction. So we decided to have an integrated this small chip of a Prager sensor, cover it with a border roof and silver adhesive. And we are now
1:03:07
studying how to send this signal through a Wi-Fi to a remote sensor inside the operating theater in order to make an alarm if we create a greater Prager to warm us to remove it and release the Prager
1:03:25
from the brain.
1:03:27
Another thing we are now still not in research still is to have something like a stent to cover the suction, the surgical sicker handle. With four touch points, these are an impedance sensor.
1:03:48
Whenever I touch anything by the measuring the impedance of it, I can't say. whether it is a nerve tissue, is it a fibrous tissue, is it a nerve, is it a vessel? I can't compare it without the
1:04:01
need of the neurophysiology. Another thing, this is now we are way too going, it is to build an inside the needle holder, a few vibrators with a sensor, so that in dealing with a tough tissue,
1:04:17
these vibrators will work in order to push the handle and try to help me in suturing in tough tissues.
1:04:29
So in conclusion, these concepts are not recalled previously and we face many unpublished disadvantages in using classical instruments, but we always accustom ourselves to the engineered design and
1:04:44
accept what they, companies offer, especially the classical instruments. We have to review the instrument, design evaluate them according to this micro-ergonomic criteria and design to make the
1:04:57
instruments more effectively used by adapting their design to the surgeon's hands. This paper has been issued in
1:05:07
last August in the world in neurosurgery. And for the PEN legal holder, we created patent registration locally. And thank you very much
1:05:23
I have a question for Dr. Faraj. So that's pretty amazing work with the sensors and the applying ergonomic principles. I think this is so critical and universal. I mean, it's not - it goes beyond
1:05:40
neurosurgery, right? This goes beyond - it goes to all technical fields, including general surgery. You mentioned you using the 3D printer in the lab What type of 3D prayer do you use?
1:05:55
Actually, the 3D printer, we started our work with it. Channel one, with cost less than 500 US dollar. There's not a complicated one, just like the upsurgeon company, which manufactured these
1:06:11
simulators for brain surgery 31 just It's. training.
1:06:17
It has a good, very well result. And besides, you have opened the talk about other disciplines. Actually, now we are trying to cooperate with general surgeons in order to apply this method for
1:06:33
liver surgery with deeply liver masses tumors. And we are just - we start to cooperate with them about it. Yeah, that's a perfect example of how neurosurgery always leads the world, right? I mean,
1:06:48
we basically invented anesthesia and gave it to the anesthesiologists. and now you're developing tools and giving it to the general surgeons. So that's the way to do it. The diaphragm to.
1:07:01
Right, that's right, the diaphragm. Yeah. I had something for Dr. Medefaras. I think that pediatric neurosurgery is waiting anxiously for his
1:07:14
sensor in the tip of the retractors because the cerebellar mutism usually seen after postiophosphorus surgeries due, I think, to the excessive retraction of the cerebellar hemisphere and damage to
1:07:27
the anti-nuclear, you know? And I do remember I had, we all speak of 100 students and after I had a couple of patients like that, I just decided to rely on the ability of the assistant usually at
1:07:43
the resident and outstanding residents at UCLA to
1:07:48
actually do not retract extensively.
1:07:54
retraction, the lateral retraction, and the measure of the pressure accepted will have a great impact. And I agree with Dr. Barrie that will have an impact below, beyond, as they are saying,
1:08:10
they will be using in the surgery, you know. And going to Dr. Barrie final scene, we have general surgeon, and we have martial surgeons. We have the martial surgeons. Actually, I hope in the
1:08:24
next two weeks, we will able to have the first prototype of this
1:08:40
pressure sensor model, and try to work on it on our patient. Dr. Vigner, I'm really very much impressed. I'm not surprised with your innovation, to modify things to create things since you were
1:08:41
a student, you
1:08:46
were
1:08:48
distinguished. Very impressed. and I'm so happy that you are leading the new innovations in the country. This is a spectacular, spectacular accomplishment and I congratulate you on independently
1:09:05
pursuing this on your own when you weren't able to find people who would support you. I think you've had some major discoveries that will have influence around the world, not just in Iraq. I think
1:09:25
from Dr. what he says, that's your personality and I admire that kind of personality that is creative and innovative and wants to move forward. And what you've accomplished is absolutely
1:09:41
outstanding.
1:09:43
I would encourage you to
1:09:47
To summarize your work, we'd be happy to publish that and publish anything you'd like that needs to have exposure to lots and lots of people. But I just compliment you on your individual creativity
1:10:02
and persistence to achieve excellence. Excellence. And I think the young people who are listening to this and watching this, you have seen presentations today
1:10:17
that are outstanding and creative.
1:10:22
You have nothing to feel inferior about in Baghdad, Iraq. And Dr. Barrie has already told you that in regard to your stereotactic and functional neurosurgery. And Dr. Kalomi has outlined
1:10:36
outstanding people you have
1:10:40
and Dr. Hose made a presentation of one of our meetings. And next to him was sitting a worldwide famous intensive care person who was a neurologist who was shocked to hear the progress that was made
1:10:55
in Baghdad, Iraq. He said, you do things better than we do. And he was full of one of the best hospitals in the world. And he said, we ought to hear more about you and what you're doing. That's
1:11:06
what people are thinking. And Dr. Faraj, you are in that tradition and we congratulate you for that outstanding work.
1:11:17
The speaker is
1:11:20
Heba Aldulamir, neurosurgeon, trainer, Arabic board of neurosurgery, Dr. Saad Alwittriq, neurosciences hospital, Baghdad, Iraq. The topic is establishing a world-class functional neurosurgery
1:11:34
program in a low to middle-income country
1:11:42
Everybody, you know that.
1:11:49
functional neurosurgery. We can start with next, please. What's the neurosurgery worldwide? And a field divided into three major fields. The structural neurosurgery as vascular, scovase, the
1:11:59
final, something else. Functional neurosurgery, that deal with the functional anatomy and the functional pathology of the body. Because attractive neurosurgery, as we know, the new era of the
1:12:13
brain-gate theory with the Profis ordinal and what we are doing for brain and machine connection by what we say be constructive neurosurgery. Actually, it's limited, but it started. I hope it will
1:12:28
get more improvement in the future. Next. I would like to start in functional neurosurgery in Iraq The first slide is showing the functional radial surgery. It's about four gamma knife devices. to
1:12:44
icon and to perfection models. The number of patients done from 2016 to now are more than 6, 000 cases treated by gamma-knife. It's used for usual neurosurgical indications and for functional
1:12:59
indications like etriginal neuralgia, glossopharyngeal neuralgia, epilepsy, medial temporal secularosis, angelastic epilepsy. Also for
1:13:09
fibromyalgia we used hypophysic tummy
1:13:13
Next, the structural functional neurosurgery done in our center by callosetomy for epilepsy, temporal lobectomy also for epilepsy, NVD for trigeminal neuralgia and for hemifacial spasm, also for
1:13:27
selective dorsal rhizotomy for spasticity. Next, now we'll go for the important chapter which is a neuromodulation and functional neurosurgery.
1:13:39
First chapter I will say about the vagal nervous stimulation for epilepsy control. There is a committee of three epileptogenic neurologists agree for implantation of device. And in Iraq, we have
1:13:51
more than 400 implants of vagal nervous stimulation would be very good results. The second one I will talk about spinal cord stimulation. We have it for pain management. We didn't start it yet for
1:14:03
movement as we have a few centers on the world that start using this spinal cord stimulation with high frequency in the programming for movement enhancement, of course, with the second feeling of
1:14:16
movement, new feeling of movement for the patient, but it started with the course of three months of physiotherapy that you start doing movement, spinal cord stimulation for movement enhancement.
1:14:29
In Iraq, we know that some patients with motor improvement and others with even sphenic scary control. The case is totally about 300 implants Now we'll go for sacral nervous stimulation in era.
1:14:46
Sacral neuromodulation, it's important for overactive blood as we know for urinary retention. Next, for also for chronic fecal incontinence.
1:14:57
Next one, we have this view of the S1S2, and we'll go for the S2 targeting the sacral nervous reef. We can go rapidly for this view, because many of us know the technique for implantation of the
1:15:13
sacral nervous stimulation.
1:15:17
And in summary,
1:15:21
the conditions of overactive blood syndrome, we notice that it's the most important and the most beneficial for patients with sacral nervous stimulation. In Iraq now, we have around 100 patients
1:15:34
with sacral nervous stimulation therapy Now we can move more
1:15:42
if we can do next.
1:15:45
Next. Next. Next.
1:15:50
That's the procedure of implantation. We all know that. Next.
1:16:03
And I talked about the summary, we are really happy with overactive weather syndromes. Now we will move to intrathecal pump therapy for spasticity and for pain.
1:16:15
For spasticity, we use baccalaureate, we all know that spasticity is a loss of inhibition of motor neurons causing excessive velocity-dependent muscle contraction and why we are using GABA receptors
1:16:30
econist by baccalaureate and try thickly. The prevalence is really high in Iraq and spasticity because it's about 80 in Cp patients and cerebral palsy patients and also we have a lot of war victims
1:16:47
with a spinal cord injury and that makes a really need for baccalaureate pumps. Next please Yeah Yeah. Our own medication we used before was baccalaureate,
1:17:07
benzodiazepine, dantronins, garpapentins, but when using the pump we are using only the baccalaureate. Next please. We are using botulinum toxin rotingly for all patients with dyspasticity and
1:17:22
patients with dystonia also get benefit from a botulinum toxin injection. Next one, next slide. is talking about intratical baccalaureate and SDR
1:17:33
for patients with spasticity.
1:17:37
I can go directly.
1:17:41
What happens during surgery? We are preparing the patient, placing the catheter. Which slide do you want to heaven?
1:17:50
To the photos please.
1:18:06
This is the full system of the Baccala fume pump, it's on intractic called catheter insertion and intra abdominal reservoir, unconnected by a tunneling catheter, and dropping a drug as we want as
1:18:20
morphine or baccala fume, you can go for next all its rapidly, all the
1:18:27
the photos
1:18:34
I'd like to save time for the videos
1:18:47
And here what we are doing in the programmer, it has a compact lot of fume pumps in Iraq about 500 patients with backloafin and after that I will talk about infusion pump for pain. We are using it
1:19:01
for cancer pain patients mainly and in Iraq we have around 100 surgeries, 100 patients with morphine pumps, some of them die because we are using it as a palliative for cancer patients mainly but
1:19:16
even for CRP we are used, we used some morphine pumps. If we can go directly to deeper brain stimulation summer I will be thankful.
1:19:27
Which is
1:19:29
next week
1:19:35
Actually, I will talk briefly about the deep brain stimulation. regulation and rapidly is the point of passion for every functional or passion for every functional neurosurgeon next one is the
1:19:47
history of DBS started from Sir Cooper and that was on 1952
1:19:54
after he is incidentally cutting a coroidal artery and Coroidal artery he saw the
1:20:02
patient after surgery was a tremor is subsided and Also rigidity and No, Henry Paris is so he think that I did as a truck in the cinema Especially he think about a them after that he used a whole
1:20:19
foreign injection in a global spaly dust and the things that developed over the time until the era of Binavid Serallin Binavid he's a French Algerian neurosurgeon and he used the stereotactic and
1:20:35
beginning of the deep brain stimulation. and FDA approved that in 2001 for VBS and STN. From that era, we are starting working with DVS and
1:20:52
what is that DVS? DVS simulation is a little bit wrong using a neural modulation connecting to intermittent pulse generator by an extension wire. It's a minimally invasive technique. Next, is
1:21:06
there any other options rather than deep brain stimulation? Yes, we have radio frequency, we have gamma knife, we have high-focused ultrasound, which is started nowadays and I think it started in
1:21:19
America, it started in Israel. It was good results. Also, do do do do do do do do do do do do do do do do do do do do do do. Retail transplantation done, but I don't know about results. It's
1:21:27
not such promising.
1:21:31
The indications for DVS as we know, it's motor fluctuation and
1:21:38
movement dis-order patients, patient. The
1:21:42
dyskinesia are medically refractory tremors and patients with medical intolerance, which means drug side effects. The DBS workflow is the pre-frame MRI, the frame fixation, the poster frame we're
1:21:54
using the stereotactic imaging by CT on the MRI, planning to target and industry the trajectory and operating the stage.
1:22:10
After the work of law, we can see some photos about in our center we are using Lixal frame. All the surgeries I'm doing and actually I'm old. All that success for my mentor who supervising every
1:22:25
surgery with me step by step, Dr. Munir Hamas. I will be thankful for him lifelong. We are using Lixal frame for all
1:22:34
the surgeries and we're using the still the station The Ministry of Health is applying us with only Meditronic. So in Iraq, we are using Meditronic deep
1:22:43
brain stimulation. It was previously active a PC and you know they are changing now to percept, which is
1:22:53
the sensing one that can help us more in programming of the patient
1:22:60
If you come next to the imaging requirement, it's a deep details.
1:23:08
Next. Okay, should I go for. Here we can go for. Core.
1:23:12
Yes. This is fine. This is fine. Good. Go ahead. This is the
1:23:18
still this station
1:23:21
we are using using the
1:23:23
pre-surgical MRI and done day before surgery, then a day of surgery and we are using CT scan with the frame, then make a fusion of both of them. By T1 image, we can make the ACPC line and finding
1:23:39
the midcomyshuro point, then go for anatomical localization. We are using anatomical localization always for posterior part of ATM because it is the sensory motor of
1:23:52
septalamic nucleus. In our center, we are preferring septalamic nucleus for Parkinson's patient, especially with the all three symptoms of Parkinson's disease. And if GPI also we are going for GPI
1:24:05
for
1:24:07
anatomical localization, using them. You know, if you are functionally working, functional working, in neurosurgeons, we can go from midcomizura point in a three-dimensional 12 plus minus four.
1:24:20
We are making it two and then minus plus four. We are going to the target of, for example, ACN in this ratings, but we are going to visualize the target directly just near to the ready nucleus.
1:24:35
We have a three-test line MRI It's a good thing in our center. We can go for photos of this summer. And the photos you send it or within the presentation? No, here, no, here, just next
1:24:53
to
1:24:55
everyone. Okay, sorry. So please. This is the basal ganglion atome, the important anatomical landmark for living in this simulation. Here is a subthalamic nucleus. We have not to touch the
1:25:05
anterior thalamus because it will deal with them in detail. to make something abnormal with the patient behaviors. Here, we can see the red nuclei, which is the two round, deeply black color,
1:25:18
just later on above to it. We have that sub-tynamic nucleos. And the targeting is so easy for functional neurosurgical work. After that, next slide, please.
1:25:36
That's the last - this is photos from our planning. Next. Mm-hmm.
1:25:44
Next, please. Next, rapidly, if you come, I will just -
1:25:58
This is the stem lock what we use, this is the only bare hole that we will do for the patient, so it's minimally invasive procedure. This is the micro-targeting drive that we are using to insert
1:26:09
the elocate throat inside the sub-salamic nucleus in a few millimeter accuracy. Next, please
1:26:19
Yeah, I'm doing this slide, but there is a little bit delay between the
1:26:25
serene and the sub-salamic. Yeah,
1:26:31
that's the elocate throat insertion. We are putting a wire for checking neurophysiology for the
1:26:40
impedance and every part in the brain have its own wave in
1:26:48
the
1:26:51
neurophysiologic screen So we can check, verify our anatomical localization by neurophysiologic. verification, then the bioengineer gave us a stimulation with that micro targeting a little noise,
1:27:02
and the neurologist will be with me in the surgery. Actually, that's before, now we go for a sleep surgery, we didn't need the neurologist now, and he will check the response of rigidity and of
1:27:15
tremor immediately intraoperatively. That was before, but as I learned from Kim Po-Shile, Professor Kim Po-Shile, even Professor Footy, Kelly Footy, they say it's good for a sleep surgery and
1:27:28
it's okay for a sleep surgery. Only anatomical and neurophysiological localization. As I said, STN is the best from our experience.
1:27:43
Actually, some of you can go to the end of the presentation
1:27:51
only the numbers. of the patient and in place of work, the numbers of the patient which is the slide 1, 2, 5.
1:28:13
is that okay? Yes, number of patients already done in Iraq totally 230. We have
1:28:23
two periods period A, which is 2009, where my mentor started with it, Dr. Munir Hamas, and he did a total of nine cases. Then we have a stoppage because we have no supply from the government and
1:28:37
it's only governmental work. So the period B, which is started from 2015 till now, which is
1:28:43
containing 221 patients with deep brain stimulation. They are between Parkinson, between this Tonya. We did turret syndrome one. We did one hunting times Korea because
1:28:58
he presented early in age and we are planning to do some new extends of indication. And now we'll go for the places in Iraq. That's where we are doing the surgeries. It's on the slide 1-3-0.
1:29:13
Okay, in my center in neuroscience's hospital, we did a totally of 170 patients. Also, we extend the work to the Sino hospital, which is in Baghdad, the neurosurgery hospital, which is also in
1:29:26
Baghdad, also to the south of Iraq, in Basra, and at the topmost north of Iraq, and actually money. Okay,
1:29:38
so we are expanding the work. We are training the neurosurgeons, and we can go. The slide one is V5. I just want to show that man that I really respect him. He's a famous artist and Hollywood
1:29:54
artist. Michael J. Fox, who found a foundation, a big foundation in Canada, and we connect with him and a lot of researchers he found by his foundation. You can go for the other videos, so
1:30:12
please sound like that. the extra videos. Yeah, please.
1:30:19
From our work, I will show you some videos for the patients
1:30:26
and some photos for MVD cases because as we consider my corpuscular decompression as functional surgeries. Okay This one, the first one, yes, this is the first one.
1:30:45
So, this is a drill.
1:30:49
It's okay for this one also. This full video
1:30:53
is a patient with Parkinson's disease, satsamami can you clear bilaterally and started for him with active APC, intermittent pulse generator, and after programming you can see the video
1:31:15
Actually, it's not such obvious for my sacrine, is it okay with you all?
1:31:22
Yeah, I think it's clear.
1:31:25
Okay, we can notice this tremor
1:31:29
of Parkinson's patients, and after making the battery on, we can program the patient until it's subsided The best thing in the neuromodulation is that we can regulate all symptoms over the time,
1:31:45
not like lesioning, because when we do lesioning, we just make a cut of time. We do this results
1:32:02
only, but for the neuromodulation, we all know Parkinson's is a regressive disease, so with time we can change. Please make this video. So this is the next patient we are seeing He has a rigidity
1:32:07
trimmer and even tongue trimmer, Parkinson's patient, primary Parkinson's patient,
1:32:14
on the date for deep brain stimulation
1:32:20
and I have this yes that's post-operative
1:32:27
walk you can see he's moving normally he has hand the swings
1:32:34
unstable gate
1:32:38
almost outside it also the
1:32:42
best thing in deep brain stimulation is a very good selection by a good neurologist movement disorder neurologist and precise targeting and a good programming after the surgery so it's teamwork I
1:32:58
think that's the last patient pre-op yeah can we show the same officials as I'm patient
1:33:06
yeah this is the impression this is the pre-operative one
1:33:13
We use it by micro scope, not by indoor scope.
1:33:21
You can show the face is softer
1:33:29
He has some sort of, well, wonderful results, wonderful results and you can show the after the last video
1:33:46
Here, the thing is stable after surgery, about 10 days after surgery, this video. As we know, it's not immediate results with hemifacial spas and long-time patients. After 10 days, he's stable
1:34:07
and I'm sorry for technical errors that came and I think it's okay for that. If we can talk about DBS, I will talk some morning.
1:34:20
Thank you. Thank you, actually. Thank you Heba,. And we are sorry for the technical issues and maybe sorry for the delay. I'm not very professional in this.
1:34:33
Yeah, I would thank you again, Heba, for that. And I will start with Dr. Al Southbury, if you have any comments. Yeah, that was a great overview of all of functional neurosurgery. So that's
1:34:49
very impressive that you were able to summarize the totality of functional neurosurgery like that in one presentation. And it sounds like, you know, I think obviously we're biased as functional
1:35:02
neurosurgeons, but in my opinion, my humble opinion, I think functional neurosurgery is the epitome of combining technology science and surgery. And the fact that you're doing it at the highest
1:35:14
level, it says something. And basically I see no difference between really how you're doing it and how we're doing it. I mean, you're just up there following exactly the standards that have
1:35:27
already been, you know, set worldwide. So I think you're performing functional neurosurgery at the highest level of the profession, which is, you know, it's great to see that.
1:35:40
And in terms of your cases, I had a few questions.
1:35:45
the DVS cases you're doing, are those awake or asleep? Before we start with awake cases, and then first part awake, and the second part with IPG with plantation, I make them under GA. Now, no,
1:36:01
we are going for a sleep, totally a sleep surgery, which is actually less time and such accurate, like awake. Yeah, and for the sleep cases, what do you use for your intraoperative imaging? CR.
1:36:17
Yeah. Okay, so you're using fluoroscopy, very good. Yeah, yeah, fluoroscopy. And you know, while engineering, drawing
1:36:27
the cannula for me and the arc of the leksel frame on them, that lead is inserted exactly on the place. Very good, yeah. I think, and in terms of the targeting, are you using microelectro
1:36:41
recordings for all of your cases
1:36:45
Yeah, he's using microelectroelectric recording and it's important, I think
1:36:50
I can't ignore this step till now.
1:36:54
Yeah, especially for a sleeve, right? I think microelectroelectric recording is critical. We actually migrated away from using microelectro recordings for VIM, for essential tremor. So we still
1:37:10
use it for, we do all our cases awake and we use microelectro recording for GPI and STN. But in cases of essential tremor, I've stopped using microelectro recordings in just awake testing. So I
1:37:25
think, and that's just, yeah, that's just at our center. I think if you look at other centers worldwide, there's a mixture of some people are still using extensive microelectro recordings for
1:37:37
essential tremor and others are doing it completely asleep, such as Dr. Burchall. that you mentioned. Yeah, that's a poor child. And, you know, we have only one case of Robros final trimmer
1:37:51
after road traffic accidents. We make it as, you know, this double target for passing from STN to ZOM and something like that. But also we are using micro-electric recording for both sides. Yeah,
1:38:05
another, yeah.
1:38:09
Yeah, another approach for those rubral trimmer is also VOA, a simultaneous VOA and VIM, stimulation is another approach that people have described in the literature. But we didn't get here. Yeah,
1:38:24
that type of trimmer is very difficult to treat in general, I find.
1:38:31
But yeah, I think this is really - Good to have, we have low number of rubbers by not trimming marks So I think it was good with the double target thing.
1:38:44
Yeah, and I noticed you have a lot of Parkinson's patients, but not a lot of essential tremor patients. Is that just a difference in the demographic in Iraq?
1:38:56
Actually, we have about eight percent of population with Parkinson's.
1:39:02
So it's the highest in movement disorder And all patients waiting lists about 1, 500 cases waiting for the brain stimulation devices, because it's totally free for the patient. It's governmental
1:39:17
supply, so we have to wait for that. And about 70 percent to 75 percent of them are Parkinson's patients Others are, you know, dystonic patients, and even we are working with secondary dystonia.
1:39:34
Even, I don't know, good results will take in very sometimes. And Tourette syndrome, one patient of Tourette syndrome. patients with Huntington's and one patients with Raprospinal tremor. The
1:39:48
mass is parking some patients. What about pediatric dystonia patients?
1:39:56
We didn't start it yet. I see. All dystonia we are doing for adult dystonia.
1:40:04
Yeah, I'm getting very impressive the time you're building there Outstanding. Outstanding job. I asked one question from Dr. Heba. Why do they have such a high number of parking zone? Because
1:40:18
they did a study in California that the pair areas which were given their poisons for the pesticides, those country people, they were all affected
1:40:32
with parking zone. This is one study I know. So maybe somebody should look at the thing because it's a very high number of Parkinson's. That's according to Dr. Iba. Maybe somebody to look at that
1:40:44
one to see, what is the reason they have so much they're not logically sold over there, because of some exposure to some chemicals or something.
1:40:55
Actually, as you know, Dr. Parkinson's disease, it's something related to the baminergic close. And all we are dealing with now are primary Parkinson's. So it's primary cause of the baminergic
1:41:07
close. So it's Parkinson's per se, about the cause of Parkinson's disease. A little are familiar, but the majority are idiopatic. We are happy
1:41:22
to look for the cause and - I'm gonna do it over.
1:41:26
The speaker is Ossoff Barry, Assistant Professor, UCLA Department of Neurosurgery, Los Angeles, California, United States of America The topic is Advances in Functional Neurosurgery.
1:41:43
Stereotactic treatment of failed chronic low back pain.
1:41:48
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.
1:42:01
Actually, the first university in the world is in Baghdad. And actually Baghdad is a city that was built for academia from scratch, right? It's the only city that I know of that was built for
1:42:15
academia. 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
1:42:30
surprised 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.
1:42:42
sharing some of my work. So I'm going to 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 for chronic low
1:42:52
back pain. These are just some disclosures.
1:42:57
I have some NIH funding on this project, this first one. So
1:43:04
Dr. Bull Amir already went over a lot of this. In the
1:43:08
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 human
1:43:21
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 us a big if, but if we can do that, then we can modulate these
1:43:34
things. And these are areas that are we're under intense research throughout the world. And eventually, we're going to look at enhancement of function. This is where humanity is headed, and
1:43:47
functional neurosurgery is going to be at the forefront of this. This is going to change humanity eventually.
1:43:56
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. You can measure it objectively. You can see a tremor
1:44:09
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 internal state
1:44:20
of the human being. And it's very hard to get a good measurement, an accurate, objective measurement of these things, so it makes it very difficult. It makes it more challenging. But today I'm
1:44:31
going to talk about why do we want to develop therapies for pain? We know that this is very expensive to society,
1:44:37
So in fact, somebody told me that the most common reason 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
1:44:47
back pain. And as we get older, that becomes worse. And so traditionally there have been different ways to treat back pain and pain in general. And today I'll focus on deep brain stimulation. We
1:45:00
already know that spinal cord stimulation has been used for this in motor cortex stimulation.
1:45:06
And in terms of deep brain stimulation, these are the traditional targets. So the periacodactal gray and the thalamus, these go back to the 60s and 70s. And we know that the PAG is good for
1:45:16
nociception and the VPN, which is the sensory thalamus. That's a better target for neuropathic pain. But these are not, although these have been used, they're not very good. On average, you get
1:45:28
about 50 chance of improving pain when you look at various series of patients. So there's variable efficacy. randomized control data are lackey, and we don't understand the underlying mechanism of
1:45:42
how this works.
1:45:44
And now there's been a paradigm shift in neuromodulation for pain, and we think of pain as opposed to nociception. So nociception is the sensory phenomenon. The pain is subjective, and pain is the
1:45:59
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 work
1:46:11
that was done at Northwestern University using functional MRI, showing that circuits that are involved in affect play a central role in chronic pain. So you can see here this is thermal pain, and
1:46:26
normal people involves the sensory pathways, and thermal pain in chronic patients also involves sensory pathways. But when they experience or spontaneous. chronic pain, it involves these affective
1:46:39
circuits that you see here. So this was our approach. We already know this as neurosurgeons. You can do anterior cingulotomy. This is from Valentine. This is from decades ago that showed that you
1:46:53
can go and do an ablation of the anterior cingulate. And these patients, they still feel the pain. They can still tell you that they feel the nociception, but they're not bothered by the pain
1:47:02
anymore. So you're modulating affect in this case, using a thermal lesion of this area. So we model pain as a combination of activity in neurons along these different dimensions. So there's a
1:47:16
cognitive dimension, physiologic dimension, affective dimension. And there's some combination of neuronal activity will lead to pain. And the role of neuromodulation is to push the neuronal
1:47:27
activity away from this into a pain-free state.
1:47:32
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 anterior cingulate cortex. But all of
1:47:44
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
1:47:55
taking 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
1:48:07
patient-specific optimization. So our hypothesis was that we were going to use Area 25 as a target. So Area 25, also known as CG 25, is located here. It's a sub-genuine cingulate cortex. And a
1:48:22
lot of research has been done on this target that shows that when patients are depressed, that this is a hotspot in the brain. And if you do deep brain stimulation to this area, and patients
1:48:33
respond. This is in responders that had major depression. and they had improvement in symptoms, you can see that the hotspot becomes a cold spot. And so there's been a lot of research done on this
1:48:43
area. And people that, the some researchers in my lab use trichography to show that this area is connected has high connectivity to the prefrontal cortex, the ventral striatum and the anterior
1:48:57
cingulate. So we hypothesized that deep brain stimulation in this affective circuit should be able to improve symptoms of chronic low back pain So our paradigm shift is that pain is a brain state.
1:49:10
It is not a spinal cord state. It is not a peripheral nerve state. It is a brain state. And in order to treat pain, you have to go into the brain. And so we, at that time, Abbott was the only
1:49:25
manufacturer of these
1:49:27
segmented leads. So you can see traditional deep brain stimulation uses a cylindrical lead, whereas segmented leads allows you to direct the current. in specific directions. And so
1:49:44
this was our lead of 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
1:49:56
treat pain. And this 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
1:50:10
patient has their own optimal settings that we discover. And then these are used as either the active or sham settings. So when we go to active versus sham, double-blinded crossover design, the
1:50:23
active patients will get their 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
1:50:32
you go to sham so this is a blinded withdrawal design. And then once we're done, we will then unblind the patients and we'll look at the tractography and we'll try to optimize patients based on the
1:50:42
imaging. So this was the design we went to the NIH to get funding for this and we received funding to do this in the initial set of 15 patients. So we're happy to announce that we have done our
1:50:56
first patient recently, earlier 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
1:51:11
failed spinal cord stimulation. And there was no preoperative
1:51:16
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
1:51:29
candidate. We did a trichography to identify the best target in this subgenio-seniolet region using one of our protocols. And then based on this target, we took the patient to the operating room
1:51:42
for deep brain stimulation. And we use a standard setup. So in our hospital, we use this alarm. This is the metronic alarm for intraoperative imaging. This is, again, we use a Lexal frame as
1:51:54
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 frame that
1:52:09
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 you can
1:52:21
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 microelectrode recordings And again, we are doing this operational
1:52:34
way. the patient is able to do some tasks in the operating room during the surgery, as you can see here.
1:52:42
And then once we are happy with the location, then we secure the lead in this fashion to the skull. And this is the post-operative imaging showing the location of the electrodes in this patient. So
1:52:53
we're targeting the bilateral sun genial cingulate 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
1:53:04
three weeks. And at approximately one month, he had an improvement in pain to five out of ten. He was actually a gym instructor, and he was able to work out after one year. He had not done any
1:53:16
workout 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 want to
1:53:29
also briefly show you what we do in the operating room. So our lab and studying human emotion and reward and affect. And the way we do this is that because we're doing our surgeries awake, you can
1:53:43
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
1:53:54
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
1:54:08
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
1:54:21
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 orbit of frontal cortex two areas that we. know are
1:54:34
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
1:54:47
depth 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
1:54:58
micro 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
1:55:10
rewards. So when 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
1:55:21
choice was easy 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
1:55:32
has something to 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
1:55:46
that Dr. Volamir mentioned earlier. So this is a
1:55:52
technology that is incisionless. There's no surgery involved in this. There's no implant. So this is a special helmet. Inside this helmet, there's a thousand transducers that send out ultrasound
1:56:04
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 to use radiation. So the advantage here is
1:56:14
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 while the
1:56:24
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. a special frame, this is a CRW frame that we apply under a local
1:56:37
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 circulated over
1:56:50
the scalp. And then we do the sonications with MRI guidance and you can see this is MR thermometry. The MR thermometry is showing us the temperature of the lesion. And so we can start at low
1:57:02
temperatures such as 44 or 45 degrees Celsius. And at this temperature, you will not get a permanent effect. It will only last for a few minutes. And so you can do live adjustments until you're
1:57:14
satisfied with the location. And once you're satisfied with the location, we go to the medium temperatures to confirm. And once we confirm, we go to the high temperature to solidify and make it a
1:57:24
permanent lesion. And that lesion will be about the size of a P. So about three millimeters cubed. And you can see this is my notes from a recent case. We did a total of 12 sonications in this
1:57:34
patient and we are gradually increasing the power and gradually increasing the temperature. So at these temperatures, we're making a permanent lesion. Once we have confirmed that location, you can
1:57:47
see here he's getting good relief of tremor by the time we're at the 11th sonication. So this takes about one hour and then the patient goes home immediately after the procedure. And this was the
1:57:59
same patient. This was before, this is a patient with essential tremor You can see pretty severe tremor prior to the procedure. You can't even draw a straight line. And this is immediately at the
1:58:08
end of the procedure. So you can see that there's a greater than 90 improvement in the tremor here in this patient. And this is what the lesion looks like on post-op day one. We get an MRI and you
1:58:21
can see the lesion located in the fallamus here
1:58:26
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
1:58:37
arrays in the motor cortex and the pridal area. This is a collaboration with Caltech. And this is being used in patients with tetraplegia to try to restore function in these patients. So we're
1:58:50
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 hands or legs. But by decoding these signals, he's able to play
1:59:02
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 on designing new electrodes to use an epilepsy. So currently, as
1:59:16
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 patient's skull. And then they have to be attached physically to a
1:59:25
recording system, which is very cumbersome. we're working with the bioengineers and electrical engineers to design electrodes that are wireless and we can keep these inside the scalp and then
1:59:36
potentially in the future we can send the patients home and and keep recording from them for you know over several weeks. Currently we're limited to recording in the hospital for about one to two
1:59:46
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 send the patient home for one to two months once we're
1:59:56
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 our center here and again I'm happy to take any questions and
2:00:09
thank you again for inviting me.
2:00:15
that was amazing. I
2:00:20
would hear a feedback from Dr. Riva on Dr. Munir, but first I would like to thank you, Dr. Ravi, that's very eye-opening and yeah, it's very nice, especially for the medial frontal cortex,
2:00:37
because we are working on
2:00:41
gyroceumet, gyrocerectus, hematoma, 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,
2:00:55
oh, this is a great work and yeah, I think the student and this resident can appreciate this. And I think that summarizes the that meeting
2:01:09
we have, what we have in Iraq.
2:01:13
on the current basis. And this is just some ideas also. So for people trying to think of function neurosagerie, here is the, I think, that's a nice demo and combination. Thank you again, Dr.
2:01:28
Bari. And Dr. Hebe, if you have any comment, Dr. O'Neill, it's up to
2:01:34
you. Dr. Hebe, would you like to make any comments? Yes,
2:01:41
thank you so much.
2:01:44
Dr. Bari, if you are talking about
2:01:54
this high-fore technology. What about expensive, is it expensive such like DBS or visioning is easier for that? Visioning also, minimally invasive process. We can't do it as minimally invasive
2:02:06
basics, but high-fore is lifeless. So, is there a big difference? between them in the cost for the patient? Yeah, for in fact, for the patient, it's very similar cost. In fact, I think for
2:02:22
the patient, it's cheaper because the 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
2:02:34
for the surgery, that includes the cost 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
2:02:47
like in Iraq, both of the deep brain 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,
2:03:00
generally, my feeling is that I think deep brain stimulation is better in some ways because you can treat both sides of the body
2:03:11
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
2:03:25
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
2:03:38
not able to do focused ultrasound on both sides of the brain, as you know, if you do a vision of the thalamus on both sides, then there's a very high, much higher risk of the patient developing
2:03:49
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
2:04:06
team of what technology
2:04:11
and actually add that. I can't imagine how you are happy to start this work. It's a newly constructed. So what's the team containing? Yeah, so for the brain machine interface team includes the
2:04:30
Caltech's 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
2:04:44
operation. 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
2:04:57
studies in the lab with the patient.
2:05:01
Also if I think one thing, correct me if I'm wrong, But what you're doing is. either unique or done by very few people around the world. Is that correct?
2:05:16
Yeah, for some of the things that we do, yes. Yeah, and so
2:05:22
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?
2:05:32
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,
2:05:45
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
2:05:59
represents to the young people here a vision of the future and what you can do and what you can accomplish, but it. It's the same as we saw earlier this morning. It takes bright people who are
2:06:11
innovative and creative, you know, with the vision to wanna pursue their dreams, to be able to make them come to reality.
2:06:21
And
2:06:24
we respect what you have accomplished. It's been, it's going to be like some of the things, other things, reverse of the world leading in our company. I think the point is anybody can do this I
2:06:36
think with the setup you already described that you have there, you can already do this. This is not
2:06:44
rocket science. I think that if I can do it, anybody can do this. Yeah, yeah, that's very good. And
2:06:56
I wanted to ask you a question if I could, so if
2:06:60
the key to your back pain, every back pain is probably the most, is the most common symptom that people present to. physicians within it, as you mentioned, everybody gets back pain at least some
2:07:12
time in their life. The major problem is patient selection.
2:07:18
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
2:07:31
paid, if they come in with pain and they get in the United States and they may be able to get off work. And people have found over time that they can be an incentive not to work. And so, in your
2:07:45
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 patient
2:07:59
selection has got to be critical. Well, I think when we applied for approval for our government agency, which is called the FDA here. They actually, if you wanna use a device for a new purpose,
2:08:12
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 they, when we applied for this, one of the
2:08:26
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,
2:08:41
we've had just a terrific session. You wanna add one other thing. I think that
2:08:49
for any other students or faculty that are 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
2:09:05
in the beginning, we were still learning 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
2:09:19
learn from you more than you can learn from us
2:09:24
I wonder if we can ask Jorge and if ask if anybody has any comments about the meeting and we can have some final comments by Jorge and Dr Cohen sorry Thank you for your show. Yeah, I consider that
2:09:39
we have that it's already Monday in Baghdad. I mean, I, I summarize it with them, and I still OSAF's
2:09:51
made a 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.
2:10:08
No, 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
2:10:24
people in 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, no? And also show something, nothing like personal
2:10:42
conversation 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
2:10:56
through the paper through the difficulties And it's not that the same, Dr. Barry or Dr. Torot. Abdul Amir to reading their papers as in this engaging in data conversation. So I congratulate you
2:11:11
all and yourself, 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
2:11:30
present still in this conversation Thank you.
2:11:35
Ollie, 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
2:11:57
are. Dr.
2:12:00
Azman, with what has happened because during the Saddam and the war, there was no problem with Iran and Iraq. a guarantee you. Everybody visited because they have a few very important Muslim
2:12:08
shrine, one in Najaf, who is the king of the Muslim Molah, he's buried there, and the capital, the son of him. So there was no problem. Always, there had been good relation. What the
2:12:24
expresident Saddam started the war and all the problems. 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
2:12:40
originally, the old old Persian, Iraq and Iran, they were all one country and the Afghanistan. Then the British government started to divide all of it. So we have to blame it on the British
2:12:54
people 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.
2:13:08
Hoss to 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
2:13:21
have such a 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.
2:13:35
OK, Shamer. Thank you.
2:13:39
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.
2:13:56
Heva presentation and your presentation, and now we have the answer for the why why. Dr. Osman and Dr. Lazarov said just, let's have Dr. Bari, let's have Dr. Bari. Now we have, we have this
2:14:09
and we are thankful for that.
2:14:13
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
2:14:31
opportunity to show our efforts to the rest of the world. And from the Dr. Barry presentation, actually several ideas will be issued. I hope to have your contact addressed. Chair, several ideas
2:14:47
and DBS, actually the first DBS done by me in 2009. I
2:14:54
distill the major work of the D-brain stimulation is still in our center in Iraq and thank you for your very nice. presentation. Thank you. Thank you.
2:15:06
Yeah, definitely you will try to connect the,
2:15:12
especially with Dr. Barry. And if the student have any question, I think there is also a student from Aura from
2:15:27
UCLA. What's your opinion today just to close with these a few comments from the students. Because that's also important.
2:15:36
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
2:15:49
information that I'm 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. go ahead and hard work in this field. And
2:16:04
I'm really excited to continue to learn and to just have such amazing mentors in my life. So thank you. Thank you. Akkam, do you have a
2:16:17
comment?
2:16:20
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
2:16:34
graduate from Akkadarak. I've given some presentations for cases in previous SI meetings, but today was something next level, if I may say so. The presentations were very inspiring. I think we
2:16:42
learned a
2:16:51
lot about neurosurgery
2:16:54
and innovation from the USA, but at the same time from our country So that was a very. special moment for us, I think. So, thanks to all the speakers.
2:17:07
Dr. Ho, 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 their
2:17:20
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 number of
2:17:36
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 neurologic disorder over there, because of some exposure to some
2:17:48
chemicals or something.
2:17:51
Actually, as you know, Dr. Parkinson's disease, it's something related to the top energy close and all we are dealing with now are primary Parkinson's. So it's primary cause at the close. So
2:18:05
it's Parkinson's per se, about the cause of Parkinson's disease. A little are familial, but the majority are idiopathic. We are
2:18:18
happy to look for the cause and we will.
2:18:25
Thank you. Thank you. I think that's something to think of. Maybe let's comment. There is alcother. Alcother is a Iraqi medical student now studying in, I think, Uzbekistan. Also with us from
2:18:34
Azerbaijan. Sorry, I'm sorry. So, yeah, introduce yourself and if you have any comment, thank you. Hello, professors, doctors and students. I
2:18:55
am an alcother, 50 medical students at the Azerbaijan Medical
2:18:59
Actually, I think this meeting was like a time machine because we started from the history of Neuraseja in Iraq, which is the past. And then we discussed everything about the future. The
2:19:10
instruments, the researchers and the audience, the ideas, it's actually greatness in three hours. So thank you, thank you for everything. And thank you for participation for all, and if we have
2:19:27
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
2:19:40
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
2:19:55
collaborate 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
2:20:11
on the next meetings, we are more than happy to do that. So I will, it's the program end from my side. I will leave
2:20:22
the mic to Dr. Osman to conclude. And thank you
2:20:29
Thank you very much, Samara, it's one o'clock in the morning. And we thank you all for coming and hopefully, you can give Samara some feedback on what you thought about this and I've already seen
2:20:42
a number of the comments and we appreciate it. Samara, you just did a wonderful job. Thank you very much. Thank you. Thank you so much. Thank you for everyone and see you next month maybe.
2:20:59
All the best and thank you, Dr. Bari for being a guest. Thank you, Dr. Munir Kamas for
2:21:04
being a guest today. And thank you, Dr. Heba Dremir. And thank you all. Thank you so much, bye bye. Thank you. Bye
2:21:12
bye. Thank you. We hope you enjoyed this presentation.
2:21:16
Please fill out your evaluation of this video after the presentation
2:21:25
The video editors were Mustafa Ismael from the College of Medicine, University of Baghdad, and Fatima Ayyad, fourth year medical student, also from the University of Baghdad.
2:21:41
We hope you enjoyed these presentations. Please fill out your evaluation of this video for CME credit it.
2:21:54
This series has been supported by the James I. and Carolyn R. Osman Educational Foundation, owner of SNI and SNI Digital and the Waymaster Corporation, producers of the Leading Gen Television
2:22:10
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2:22:22
This recorded session is available free on snidigitalorg. Send your questions or comments to osmondsnidigitalorg. Thank you
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