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Welcome to the 19th SNI and SNI Digital Baghdad Neurosurgery Online Meeting, held October 23rd, 2022. Today's introduction will be the Meeting Originator and Coordinator, Samir Haaz, from the
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Universities of Baghdad and Cincinnati
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The speaker will discuss a proposed classification system for pre-signoid approaches with possible combinations. The speaker is Samir Al-Bairmani, medical student Al-Arachia University College of
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Medicine, Baghdad-Iraq The first speaker is Samir Al-Bairmani, she's a medical student and University of Baghdad Al-Arachia College of Medicine. She's now in the fifth stage, if I'm correct.
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And she will present her experience about
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searching and writing about papers on skull base based on her interest. And yeah, the stage is your summer. You can share the presentation and introduce yourself and get us to your presentation
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Hello everyone. I am Samuel Vermoni, a fifth year medical student at American University College of Medicine. I'm an active member in husbandation program since 2019 and I'm a member of the core
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research team. So today's presentation is supposed to be three presentations about the forensic point and the combination approaches and my journey, but it's condensed to our presentation. So I
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hope to stick to the 15 minutes I'm given.
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So, my title today is a proposed classification system for placing more approaches with the possible combinations. So what is the placing more approach? Well, it's a spectrum of approaches using
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the Pinterest temporal bone, either as they wrote heading to the interconnectular regions, or as they target used to, in the regions that are purifying internal with the turi canal, is your
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girlfriend for a man, the particular private region on the brainstem territories.
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So the surgical procedure in a nutshell, and I wrote the word in a nutshell, because our main target in this paper is not to mention the surgical procedures of the targets, but rather to focus on
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the terminology on a microchar. So as usual, it starts with the skin flap muscle removal showing the muscle is segmented here with the surrounding first respond. And here the cranial name is called
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Bosea beta-sectomy because we are only dissecting the Bosea part of the first respond. It's also called infotentorial muscle redictory because we are dissecting again the bone that's facing
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the infotentorial region And also, of course, the pre-sigmoid is also an anemone that we prefer.
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So muscle edictomy is the first stage in the pre-sigmoid approach. It's the in-street pathway. Here's a picture shows the anatomical structures of it. This is the muscle ed segment. This is the
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Topano muscle ed suture, spina of Hindley. And here's after the movement of the muscle ed showing the posterior and lateral semicircle canals. and both segments of the facial nerve, the symphonic,
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and the mass of the segments. Second phase, we have skeletonization and drill opening. So this picture is after further drilling, showing the lateral imposterior since circle canals more obviously.
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And here you can see the marking of the
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drill incision. This picture after opening of the
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drill and a little reduction of the sigmoid sinus and the cerebellum showing the trajectory toward the CPA. And here is expanded view showing the cranial nerves from the fifth over to the 11th.
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Next, we've got the identification of the entrum, which can be acquired by further drilling. So the entrum can be localized 15 millimeter deep to the spinal family and the other symmetrical canal
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is greatly deep to the entron.
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Okay, next phase or next stage, we have the labyrinth, which is the check point and actually the labyrinth divided the pre-signal approach into two main corridors. These turns labyrinth in the
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interior one which is located interior to the labyrinth and the usual labyrinth in which is located posterior to the labyrinth here by the red line.
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So this picture shows the anatomy structures we are going to need in the pre-signal approach. Of course the mastoid and term we're going to need is through the mastoidectomy, the labyrinth which
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divides its two interior trans-laboranthein and posterior to a labyrinthine. And here we have the structures that might contain the lesion and become main indications for the approach which are the
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jugular foramen, the CPA, brainstem, retroclivore region, retroclivore region on the petrosophics.
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Here I have shown the subdivisions of the two main corridors, and I'm just going to name them, and this slide and then go briefly through each one of them. So here I have the posterior petrozo, as
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I mentioned, it's a posterior petrocectomy. Here I have an infra-tentorial, because this is a very important point, because if the lesion does respond to the titanium, we're going to need another
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approach to the pre-sigmoid that is going to be used to reach the lesion, and the muscle edictomy and pre-sigmoid. So in this
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line, I have five subdivisions of the anterior corridor, the trans-labranine, and over here I have the four subdivisions of the posterior planthein. So I'm just going to name them here. This is
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the partial trans-labranine, trans-cousal approach. Trans labyrinthine approach. Trans cochlear and transotic. Over here, I have the trans-troteman triangle, the retral labyrinthine. Infra and
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super labyrinthine regions, which are going to lead us into the Supra and Infra meato approaches. And over here, I have the super bubble region on the picturesque ridge.
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Okay, so this is just a summarization of what I said about the approaches that the translabranthine and tier one and
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the
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translabranthine with its four subdivisions. And I just want to focus here on the word proper here because if you search for a permit, for example, for papers, you will see that a lot of them, if
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not all of them refer to the word translabranthine as the, as the,
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Translaborantly a proper, but they don't mention the word proper because I have here the major corridor is called Translaborantly in and one of its subdivisions is also Translaborantly in but its
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proper.
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So, now I'm going to go through each one of them I'm starting with the Translaborantly in the anterior corridor and it can be divided into five subdivisions according to the boundary removal. So,
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it's divided from the less invasive to the more. The first is partial Translaborantly
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in which includes removing of part of the superior
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and posterior stem cell volcanoes. And it's a here in
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the cell So, you can then have the transpose of approach which involves removing of the common crust in addition to the superior and posterior stem cell volcanoes. they have the translabranthium
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propar, which involves removing of the all syncyclical canals. And the advantages of this approach include white surgical corridor, area identification of the facial nerve and minim ulterior
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attraction.
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For they have the transautica approach, which includes removing of all
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the syncyclical canals invading the autocapsule and removing a part or all of the cochleum And I want to pay attention here for the facial nerve as it remains in situ, which is the main
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differentiation from the next approach, which is the
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transcochlear. Transcochlear, we have here, it's rotated posteriorly to eliminate the surgical obstacles of the facial nerve. So this is the only differentiation between transautica approach and
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transcochlear, and And of course, both of them are hearings I could find for teachers.
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So next I have the ritual labyrinthine, the posterior corridor, which can be divided into four subdivisions. First, I have the infirmatal approach, which represent an extension from the inferior
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part of the initial master edectomy done. And it targets the jugular fragment and it's also called suprabolbor approach, because as you see, it's okay, it's superior to the jugular problem.
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Second, they have the transmittal approach, which presents an extension from the middle part of the initial master edectomy, and it targets the internal auditory canal on the CPA, and it's
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represent the pure virtual labyrinthine. Third, they have the supramietal approach, which represents a superior extension of the initial master edectomy, and it targets the retroclivar regions,
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and it's also called suprabolboratine approach, because as you see, it's superior to the labyrinth
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Finally, I have the trans-transtros-man triangle. And as you know, the trans-man triangle is bound by the superior petrosos-sinus, the sigma-sinus, and the labyrinth. And actually, rarely this
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approach is a long so when we use it, we usually will need a combined approach to be used with it.
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So here's just an overview of the indications we might need for each one of them Starting with the ritual lab, the indications might be bone lesions, dual lesions, or intra-dural lesions. Bone
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lesions might be tumors in the bone, dual lesions include meningeromas, and intra-dural lesions
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include vasochronomas to attempt hearing preservation. You can see here the ritual labyrinthine extends to the internal auditory canal. Trans-laborantine approach includes mainly vasochronoma So
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it's the main, I'm most indication. to use the translabenties for the severe schwannomas, all-sufficient aromomas, many aromas. And you can see here, the translabentine gives us a little bit
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more extension toward the medial side interior to the internal auditory canal. And the transcochlear, let's see it in the picture. You can see it gives us a lot more extension to the medial side,
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reaches the movement. So we can expect that it's used for midline intrazural lesions, as in the form of fly vests and the CPA masses.
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So this is like a summarization of everything I said and all these figures I just want to highlight that they are joined by my colleague, Ahmadil Kasey, who puts a lot of effort and time and
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dedication to draw them. And you can see that they are not the same
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showed you, they are upside down representing what we will see in the surgical, the surgery, I mean, in the operation room, in the operating room. So you can see this from the interior, from
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the translabranthine, and here are the electroabranthine, the posterior ones.
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So in conclusion, the classification, the stratification, is a new drug event lecture, because of the continuous advances that are anymore on the vasiveness. So this approach is used to increase
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safety nets and to decrease errors. Also, it's a more probably innovative approach, because a lot of approaches are appearing every day in the literature. So we need a common terminology that can
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be used in the medical record. Also, simplified operative terminology-based approaches, because this approach is not only used by neurosurgeons, but also can be used by anti-surgeons. general
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neurosurgeons and other skull-based surgeons. So I can't consider this slide a memorial or thankful for everyone who worked on the Prisma approach since the early '60s. Starting
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with the translabranthine approach was first described by PANS in 1904, but it wasn't stopped at that time because the complications were high, the mortality rate was high because of TSF leaking,
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so
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meningitis was the result and high mortality rate. It wasn't stopped at that time and wasn't used until William House at 1964, reused it by using micro neurosurgical principles, for instance,
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unable to talk to more removal and preservation of the fish on there. Second, they have the Transcrosal Clear approach, which was described by William, his former girl, and William House again at
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1976,
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described it as an anti-extension of the trans-laborating approach. Third, they have the Transcrosal approach described by Michael Horgan at 2000, and I can't consider this approach a bit new,
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because it's only 20 years ago, in comparison with other approaches. And it was described as a technique of hair and goopreservation in which he used a variation of partial labyrinthectomy approach,
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as partial labyrinthectomy at that time wasn't specific to remove a specific part of the bone. So sometimes may be used to remove only parts of the superior sensitive canal leaving the lateral one,
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and but now it's more specific with the trans-laborate approach. Here I have the Petrozokre enemy, actually it's not an approach, and the Petrozokre enemy procedure itself was used maybe a hundred
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years ago, but the term Petrozokre enemy was fairly squared by Osama Mifthi at 1988.
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Let's discuss in the evolution of proposal approaches. The optimal surgical technique for a particular environment in geomas is described in his amazing article that talks about the material level of
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management as you can see at the countryside. So, the next part of this presentation is the combined approaches, including the pre-signal approach.
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So, when do we use it, the combined approaches? Well, there are three criteria for a lesion So, we need the combined approach in addition to the pre-signal approach. If the lesion does respond
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to the tutorial, I'm going to need the combined, because, as I said, the pre-signal is only in front of the tutorial. If the lesion is not localized to the posterior cranial force, for example,
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extends to the middle or the anterior one. Also, I'm going to need another combined approach And if the significant extension to one of the adjacent foramina, for example. the jugular, the
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internal auditory canal, I'm also going to continue to combine. This illustration actually is drawn by me and I'm not an illustrator, but this is the first illustration I drew, hopefully not the
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last. And I demonstrate here the combinations This pink area highlighted present the pre-signal approach to present a traffic point for the approaches. And these arrows are the possible combinations.
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We have five possible combinations in here. So before I go through each one of them, it's like revise the criteria For example, I said that if the the initial extends to the middle force or the
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interior, I'm going to need another approach. Here. This approach is anterior petrosal kawazis approach. I'm going to need it if it goes to the middle for some Uh, it was.
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The lesion is part of the centaurium. I'm going to need a super centaurial approach and in addition to the infra centaurium, I can see that the arrow is stored above the bone, not like this one
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representing a super centaurial approach. And if the lesion, for example, goes to the jugular foramen, I'm going to need infra temporal force type A approach. If the lesion goes to the antenna of
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the tree canal, I'm going to need a truscigmoid approach. And if the lesion extends to the foramen organ, I'm going to need a far larger approach. All of these combined with the pre-signoid.
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So the interior proposal, Kawaz's approach, also called combined truscigmoid approach because I'm removing the interior and posterior parts of the pictures bone And
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they're also called
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also to disinfecting me and allowing
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for
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the lesion of the spanned centaurium. Sorry, if it goes to the imidophosphate. Now, the trans-centaurial approach, super-inflammatory approach, this is a green one. It can be accessed by a
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temporal subocrossibital cryoneotomy and, of course, use for lesions that spanned centaurium. Third, they have the impotent polyphosphate A approach here. It affords wide access to the lateral
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skull base from the temporal bone up
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to the upper neck and mainly used, as you see, for jugular
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foraminations and the decision can be accessed only by master edictim that are done for the pre-sigmoid. Now, the
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sigmoid approach, which is a common pre-sigmoid approach with the pre-sigmoid can be accessed by sub-oxyptoch cryonomy. and offers better visualization for the CPA. And lastly, we have the four
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lateral suboxymptal approach, which is also called posterior lateral or transchondylar approach, because it reaches the form in magna.
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And it can be accessed by posterior lateral to a condylar
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suboxymptal connectomy, including the posterior lateral of the form in magna. And lesions mainly indications here that extend through the form in magna.
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So the advantages overall of the combine approach is that it offers direct tumor visualization with minimal cerebellar attraction and hearing preservation techniques for extended lesions. So for
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example, if you think or imagine that adhesion and CPA,
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it can be accessed actually, maybe by one of the invasive pre-similar approaches like the transcochlear. But the
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transcochlear, as we know, is a hearing sacrifice. procedure. So mainly, a transcochlear is used for patients with already hearing deficits. So for healthy patients, we would prefer to use a
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retro lab pre-sigma approach with a combined rather than using only one invasive pre-sigma approach for hearing and co-preservation technique Again, it's
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a unified terminology as needed because without a unified innovative terminology, a lot of names maybe will appear like, for example, a surgeon will determine which combination will do
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intraoperatively or maybe they will add the name extended to the approach just to
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obvious the the extension in the procedure but with compliance. five variations, it will be more unified terminology that be used by the searches. So that work I just explained
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was the last thing I did in all the needs for sure. And the whole journey started in 2019 and hospital care program. As you see, here I am and this picture I was in first grade and I didn't even
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know you're an anatomy. So if you have started with me from literally zero to where I am now. So the activities I did in the last so briefly, surgeries for sure, this was in 2019, I was only
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observer. Here I am second assistant and here I am first assistant in 2022. Obligations started with one book,
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article, another article, another one article, the last one. And here's my website on research gate with six researchers contributions for sure the mentorship in 2019.
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And I remain participating in the mentorships till
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2022. This is the last one, such as VA. And also, I'm the Chief Regretary Officer in the Iraq Club. And here's my certificate from attending the Pan Arab meeting that held in Beirut, Lebanon
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in March 2022. So that's it. Thank you so much for listening I hope I didn't close this time.
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Thank you.
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Hello.
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She is only a 50 year medical student and Baghdad. I think that's the title in my mind. Yeah, I will listen first to the professors. Thank you, Sam.
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You want to make some comments? Yes, first of all them. You're calling the illustrator, I think that these initials were AOC or something, outstanding illustration, the ones on the different
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approaches. Also, your illustration, your three illustrations with those brackets in different colors, were also very, very good, and you included the cerebellum, so that's on the artistic side.
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On the other side. Sorry, you just connected the black side I like it
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a lot when you say that you mentioned that we need unified terminology. Although you are only, we are supposed to say, only a fifth-year medical student, you can, because this is a theoretical
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work, and you are read a lot about it No? Work without trying to propose your unified terminology. And then. run this unified terminology between the big names in the field in Iraq, run it
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through Dr. Ross, Professor Ross, run it through Professor Rouseman, and then of course of the original project of your unified terminology, maybe we'll come something different. But I fully
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agree with you in your enthusiasm that you spotted that the problem is a cognitive problem, it's an epistemological problem. We need a unified terminology. I mean it seems that each one who comes
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with one approach put its name to the approach, you know, and so unified terminology, work on it, be aware that what you give to the professors at the end will not be recognizable as something of
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your original work, but you will learn, everybody will actually learn from that. So,
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Congratulations. Yes. Thank you so much. Thank you. Thank you, Dr. Lazar. I should say that once I start on prasigmoid approaches here as a research, I have an idea that it's simple that the
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terminology is not there. I see some confusion So the idea start with, I contact Emma and I told her, can you dig on this terminology topic? And that was, I don't know before how much, how many?
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It was in March, six months, seven months ago. Yeah. So I just send her to that topic. Please dig in that topic because I can see some confusion And, yeah, and now I think you can tell that she
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has six months experience in those topics because she has many strong opinions for a person that. just start, just in the medical school. So I really congratulate her for that. And I would say
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before listening to comments from Dr. Osman that the illustrator was very professional. And I think for expert can understand how difficult to put an illustration to all these nine very similar
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approaches, he's also with us, I met, I met the little I see, I met just say hi.
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And give us like two minutes. What's your experience by writing this?
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Okay, my name is Ahmed. I'm a finally a medical student from the University of Baghdad. Actually my experience in illustration started with my mentor, Dr. Sandler motivate me to Two. convert my
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my special gift, which I am experienced in portrait. He motivated me to to illustration. So I have many many illustrations but lastly this one it was very perfect and I am very proud of being in
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this mentorship. Thank you
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Thank you for your for that man. And yeah Dr. Osmond,
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for six year medical
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student you know more about this idea I can tell you that it's a very confusing area for me. Everybody has a little different approach and and you got a great deal to try to to make some sense out of
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it. I agree with what Jorge said, and Sam are dead about. trying to find some unified practical, sensible system to classify this. Amit, I think your illustrations are outstanding. I might make
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one suggestion. And that is, as you
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go through the various images, first of all, I would try to keep all the images in the same orientation, left, side, and right side. Maybe you did that, but the second thing is you might have a
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little small pencil diagram or something in the corner to give the person who's viewing it a general view of what area you're talking about. You could probably take one of your slides earlier that
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shows the very different divisions you have. And so people would understand that even where the frontal part of the brain is in the back part of the brain.
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the Clavis and so forth. So for orientation, I think
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that might be helpful. And are you planning to propose a classification system yourself?
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You are correct, Professor. And I think we have that discussion and Ahmed did assume out of view for the skull and from where we are looking to be put in the corner for each illustration. And yeah,
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we are trying to make, I'm trying to make a cadaver
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pictures also. And that took a little bit time. I think it's very complex procedure to make it a typical picture on cadaver as well And yeah, we are working to make this as two-paper, one as. one
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is about the terminology in general and that suggested the classification. And the other one is that will be, I think Samha will be the first name and the other one is about what are the possible
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combinations with the pre-signoid approaches. So yeah, we are working with the illustrations and we are trying to make a better work as well to make more sense for people.
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I think I'm a, you should be complimented also. There is a very famous medical illustrator by the name of Frank Knitter. I'm sure you know him, I know he was. He made very good illustrations and
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trying to describe things with pictures in very little text. He did an excellent job, wrote many books about that or many
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publications And. A medicine can use very good illustrators. I think that's a talent
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that's always helpful because it makes sense of what we're seeing. And again, Sama, that was a complicated job for a fifth or six year medical student. I think that's very good.
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Thank you, thank you, Professor. Thank you, Sama. Yeah, I think that the idea is that Sama and Ahmed has
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the potential and has the interest, but they choose a different pathway from others. You will see in the next presentation, each one has different mindset and we are happy that they found something
32:32
that catch their interest.
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It's not easy to work on a project for six months and it's very difficult to maintain that interest
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dedicated to that topic. You love that topic. And I really congratulate some of for that. I can see that if I ask the turtle, Lazar, do you think that if she continues on that work, she will be
33:01
a
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good resident project in the future? A potential? Yes, I think so, absolutely. And I think this is a great project. And also, in this project, we'll allow you to share even to send a letter to
33:21
Dr. Osman to go ahead. Or even if you want to, Dr. Almaty. And then that will create something with your name, with your, with your thing. But everybody, including everybody in there, no?
33:35
And that will be very, very important, because you are pointing to something that everybody is saying here is missing, are unified. theory, a unified classification. And then when you start with
33:48
the idea of the unified classification, you may end up doing something different, the classification according to the volume of the tumor. Because we say meningioma, schwannoma, yeah, but there
34:00
are meningiomas this size and there are meningiomas this size, the same as the atishwannoma. So maybe you will find that the
34:08
classification has to go according to the volume, or according to the age of the patient. I don't know, but the wonderful thing is that you start a trip and then you don't know where you will end,
34:20
but wherever you end, you will end up being much richer in the literally.
34:28
I can say one other thing that I hope you're going to make this a publication,
34:34
Sambar and Asama and Ahmed, and two, maybe if Ahmed is interested he help us with some illustrations with SI or something like that. I think he's got, both have very great talent and yeah, that'd
34:52
be terrific.
34:55
Thank you, Dr. I really appreciate that. And I would like to share my experience and my skill in the SI Oh, thank you. Thank you. Thank you both. Very, very good work. Thank you so much.
35:12
Thank you, Dr. Liza. I will just to say a last thing that the professor can understand is that sometimes I ask my friends who, one of them is a skull-based fellow, and I told them, what's the
35:27
difference between trans-autica and trans-cochlear? And he said that, he said that, Oh, they are cinnamon, and maybe it's not a device. And then get back to someone, and Ahmed, I told them
35:39
that, Yeah, no, you are digging in something weird. to have for medical students but yeah you are trying things and you are building COVID-19. I'm really proud of you both and yeah definitely we
35:53
will share an update in the future if we get this as a final result. So thank you thank you so much for that presentation and if anybody If you have any question, comment.
36:16
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36:23
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