0:03
SI Digital Innovations in Learning is pleased to present
0:13
The Jorge Lazarus Lecture Series on the origin and development of ideas in the clinical neurosciences. This course series consists of seven one-hour lectures with discussion
0:33
The speaker will be Jorge Lazarev, Emeritus Professor of Neurosurgery, Department of Neurosurgery, Ronald Reagan, UCLA Medical Center, Los Angeles, California, USA Thank
0:51
you.
0:58
This is Dr. Lazarus introductory comments to his lecture series, and we quote, The most significant number of patients with diseases of the central nervous system live in low and middle income
1:13
countries for no other reason than the majority of people are living in low and middle income countries.
1:25
Let's start over.
1:29
This is Dr. Lazarus' introductory comments to his lecture series, and we quote,
1:37
The most significant number of patients with diseases of the central nervous system live in low and middle-income countries for no other reason than the majority of people are living in low and
1:53
middle-income countries Nonetheless, neurosurgeons and neurologists from high-income countries offer most research papers on clinical neurosciences.
2:06
This disparity is prejudicial to the neurosciences as a whole.
2:12
We designed the course as an introduction to some of the tools that promote the genesis and development of research ideas
2:25
This series of lectures are provided free to bring the advances in clinical and basic neuroscience to physicians and patients everywhere.
2:36
One out of every five people in the world suffer from a neurologically related disease.
2:43
Lecture 6 Introduction to the development of the nervous system, a tool for clinical research and pediatric neurosurgery. The multiple representations of spina bifida. So, we
3:04
will give you this next lecture of our course origin and development and development of idea in neuro science, which presented by Dr. Lazar.
3:11
Thank you. Thank you. Also, as we were saying now briefly, I will let me see if I share the screen,
3:20
share the screen. This is the one to share. And was we were saying now with Professor Hoss, what we will try, what we'll do next Friday, our last lecture is the lecture will be as regular about
3:37
one hour and then we will have half an hour of time that we will love to hear your thoughts, suggestions, what needs to improve because this is the first of our conversations on this subject.
3:56
Hopefully we will repeat this next year or in six months or whenever I'm certain that and I'm certain that I'm ready to learn from your thoughts and everybody in the future would benefit from your
4:13
experience. You are pioneers in this endeavor, no? I mean nowhere in
4:20
the world,
4:23
we are doing similar things as we are doing here so today there will be a couple of movies of some of from a surgery and let me know if the transmission of the movement is of the action is good,
4:43
right?
4:45
So here
4:49
we at the start. The main concept of the of this lecture, of the series of conversations is concept. Everything, the concept, the conceptual understanding
5:08
the whole picture and then you go to a little details. These two gentlemen over there, the gentleman on the right is Christopher Columbus and Columbus is But as you know, it's the first sailor who
5:28
arrived to what we call America and is the first to report it, because perhaps the Vikings were here before, but they did not report that they found this new land, or this land. But the continent,
5:47
as you know, from the top, from Alaska down to the south of Argentina to Shuaia, or from pole to pole, is called America, is not called Colombia. And why is that? Because the gentleman on the
6:03
left, which was an important sailor, but compared to the other sailors, he wasn't that a big sailor.
6:14
The gentleman on the left with a beard, his name is America of Spusio, America of Spusio.
6:24
He's the individual who said, introduced data concept. This is what we are seeing is new land. There is something different. This is something new. And imagine this man reached to this conclusion
6:41
just sailing around the tip of what is today Venezuela and taking notes here and there. He didn't have any idea that there was another ocean on the other side. He didn't have the idea that if you
6:57
kept going west, you will reach finally China as Columbus intended. And what I mean with this is one thing is the physician, the surgeon, the fantastic surgeons, the fantastic physicians who
7:13
observe something, describe something, describe a technique. But the other one is the other that doesn't have to be the most. important surgeon in the world who says, understands that the concept,
7:29
you know, so this is a, and today we'll introduce you to two concepts which is a way that for you to make the analogy and use this conceptual way of thinking of the pathologies we will address to
7:47
the pathologies that you are interested on. So, to do succeeding research in neuroscience or to succeed in researches in neurosciences, an absolute mass is a conceptual understanding of the nervous
8:04
system.
8:06
And what is the nervous system? Because of those of you who received the PDF already know the answer. But think about it. The digestive system does digestion, the cardiovascular cardio, the
8:21
reproductive system, reproduction. endocrine system, endocrine. But what does the nervous system? It's called the nervous system. Yeah, but what's the function of the nervous system? Why we
8:35
have the nervous system at all? And the purpose of the nervous system is communication, is to communicate.
8:46
In this moment, my whole nervous system is focused in this conversation, your nervous system is focused in this conversation. But besides that, I have an awareness, whether I am hungry or not,
9:04
or how my body feels, whether I'm hot. So there is a communication between the outside, which we are doing now, and it's a communication with the inside, through the autonomic nervous system. So
9:17
that's that the purpose of the nervous system,
9:22
And when you see at the patient with pathology of the nervous system, as we discuss on the first lecture, you have to think, I mean, is this,
9:36
how's the communication working? Is he able to move to work, to see, to understand, to comprehend, to answer? So does the actual, if you think like that in this conceptual form, you will start
9:50
working in a different way when you start doing clinical research. And the neuron is the core of the system. Yes, we have glia, but we have glia for the neuron. Yes, we have blood flow, we have
10:05
blood flow for the neuron. Yes, we have cerebrospina fluid, we have cerebrospina fluid for the neuron. Everything is focused on the uses of the neuron.
10:19
To start a research career in clinical neurosciences, you need a conceptual understanding of the diseases of the neurosystem in your own environment. You are now there, but that, most of you, my
10:34
understanding, you're only about that. Most of you are in, about that So you are there,
10:48
or at least in the Middle East or in neighboring countries, right?
10:56
And that's where you have to start studying, focusing on the diseases of the neurosystem that are available for you to understand how to study. Which, by the way, are universal? If you have brain
11:13
tumors, there are brain tumors here If you have aneurysm there, then aneurysm is here.
11:19
And today we will focus on neurotube defects, a subject that I purposely choose because I know something about it, but also because it's seldom explored and it's important. So for example, you
11:36
have this paper from 2018
11:40
called study of neurotube defects at Aldiwanaya Province in Iraq. I'm sorry, I didn't pronounce it, but perhaps well So there you have
11:52
it.
11:56
And they're talking about, they have a study of how many
12:02
cases they have of neurotube defect. Yeah, compared that so many people live in, it may be that the number is not that impressive, but think about it, they have, 37 cases of neurotubed effect
12:19
per year.
12:22
So this is three cases per month.
12:27
I mean, I don't know if there is another neurosurgical disease. I don't think that they see 37 aneurysm a year in that province or three or if they see, okay, they see 50 So we are talking about
12:44
one province of your country who has the incidence. And if you want to see the entire paper, please let me know, I will send it to you, but it's available on the web. So we have one province in
13:01
Europe, wonderful country who has 37 cases a year. Wow, that's a
13:09
great number of cases So what is a neurotubed effect? When we.
13:17
where just in the beginning of our lives, you see that the cursor here, this pink thing is the wall of the uterus, and this is how we all were in the beginning of our time, in a minimum, barely
13:37
day one of our lives.
13:41
And
13:43
in day one of our lives, the blue structure here is what differ origin to the central nervous system and to the skin.
13:57
Just this,
13:59
I keep on with this drawing, with this animation, but just for
14:07
you to watch, but basically then that the emphasis is the neurotube is that blue line. at the beginning of life. It's already there present.
14:23
You see, that is the issue that
14:29
interests us in this model.
14:32
There are two layers, you know, eto-derm and endo-derm, and the
14:40
meso-derm is formed
14:45
from the thinking, from the diffusion of the
14:52
eto-derm. So what does it mean?
14:55
You have one layer blue, of which only one segment in the center, the primitive straight and the primitive node will form the center nervous system So our skin and our brain come from the same layer,
15:15
the same layer. It's the same, same, it's a thing over there. So how a layer of imaginary tissue, just this blue layer that you saw there,
15:29
transforms into a system that perceives interpreters and responds to the environment.
15:40
So this issue was solved originally by the two individuals who are in the photo in your PDF, which is coming on
15:53
the slides now. But what they had, Spellman and his student, Magole, Spellman, for this word, got the Nobel Prize. Magole died on a very young, on a home accident, some event. at her house
16:15
and she died. I mean, that's why otherwise she would have been receiving the Nobel Prize as well. So
16:23
what they came to in 1920, yes, 100 years ago, they came without a concept. They say, how come this thing becomes everything else?
16:37
So the concept that they came is they say, must be a nucleus, must be a structure
16:46
that gives origin to the other ones. And as you can see, there is no paper, there is no laboratory.
16:56
Yes, they did some experiment, which I will tell you now. But there was no sophistication. Everything was a conceptual thing, like America was Pusio saying, this must be a new continent and
17:10
spellmanan andmanroll to over sign.
17:15
Spammon, they were saying, Oh, maybe there is something. And they couldn't think the organizer must be something that organizes there. And what they did, they get embryos from a chicken,
17:32
chicken embryos in the yolk, no? Very young. And they were pulling parts of the embryo and attaching to the other part
17:43
And eventually they got chickens with two heads or two nervous systems
17:51
or chicken limbs in one thing or limbs on the other thing. They created these
17:58
funny animals that they didn't survive. But conceptually they say there must be something, something that later other researchers later in life in this century, the history of the century.
18:15
trying to define the molecular principles of the organizer, but the concept that's why the two guys don't remember, you know, for coming there must be some organizer which is a concept. So this is
18:34
the image that we just saw now, right, so the blue thing, and you are looking at the blue structure from the top. You follow me, right? Is it clear? No, no, I'm telling you, yes, it's clear,
18:49
you are looking, this is this, no, you are looking from the top. So you have in day 15,
18:60
that means that 15 days after the conception, when our parents barely knew that what other mothers didn't think or didn't know that they were a predator.
19:15
in a size of 1 millimeter.
19:19
So that thing, the organizer by day 16 starts grading this groove, right? In order to have a tube, you need to have a groove. We're talking about a neural tube. Then the walls and the sides
19:36
starts going up by day 18
19:41
And then the psalmites start forming
19:46
by day 19. And then the tube starts closing.
19:55
There is a closing of the tubes and the neural folds. So by day 22, when our parents were thinking that maybe their father was pregnant, four millimeters. And then the
20:13
bionic age.
20:16
Thank you, or thanks to the tube, to the neural tube, we create a structure from where the brain and the spinal cord and the whole nervous system develops. Of course, this is very, very
20:35
simplified, but
20:40
you understand that, or I hope, that you get the message that the neural tube is crucial to the development of the whole nervous system. And we have, in a land we province, 37 cases per year were
21:00
very stunning, perfect, folding or formation of the neural tube
21:09
Did you receive this wealth in our. No, I'm asking you because you are the first one there, or anybody who wants to answer. Did you see these images fairly well, no? With a good reception?
21:27
That's here. Yeah, it was good. Okay, beautiful. Yeah, because I was told, I mean, years ago, with this Zoom problem, those images were not properly seen sometimes, no? Anyway, so we had
21:40
this. And now, of course, when this thing closes, some of the the posterior part will be sensory, the anterior part will be motor,
21:55
and there are different molecules involved in them, the bone methods, protein, the sonnet, HR, doesn't matter. The conceptual thing is what I want to transmit to you. Spelman and Mangold said,
22:11
There must be something here. Let's find it out. Then later, let the biochemists and everybody else figure it out what is going on.
22:23
And the neural tube is not just the forming of the neural tube. You need to have the neurons. Remember we said the neurons are the essence of the nervous system. Yes, we have glia. It's important,
22:38
glia is important But the glia exists for the neurons. So this is the - this black thing in here is the center of the neural tube. No? It's the whole of the neural tube. That's the wall of the
22:51
neural tube. And from the wall of the neural tube begins a cell cycle that forms the neurons.
23:01
The neurons start from the wall of the neural tube and
23:10
then they go up. And they travel
23:16
to the gortets, to the different areas of the gortets.
23:20
And in terraces, you have two neurons, and then they will start going up. And here on the left, you have some
23:30
drawing that shows you how the glia supports the growth and the progression of the neurons through that cell cycle. The interesting question that has not been answered yet is how
23:52
the neuron knows
23:54
where it has to go or why because a visual neuron is different to an auditory neuron or a neuron from the motor cortex different from a neuron, from the hippocampus. and how they acquire their
24:12
identity. But you see, there is this conversation, the second neuron
24:21
escapes the boundaries of the neural tube and starts to be believed towards the cortex. And that is for to have this working properly, you need to have a good neural tube
24:38
In 37 people per year in
24:44
the province of a laundry, this event was not perfectly done. So there is in one province only in the country.
24:56
I'm going back in here. So we go to the study of the neural tubes of the laundry province in Iran that I just mentioned now. And we can say, what happens over there? What happens over there? What
25:14
happens here? Because we also have, you know, the feds were happening in Mexico, what happened in everywhere. You have environment, and genetics. And both things alter the mechanism of the
25:30
foliage, of the foliage acid. You can decrease methylation work. You can see there, and they're protein function, and the tube doesn't close. The tube remains open.
25:45
The foliage acid is crucial for this, for the binding of the tube. If the tube, if the foliage acid, supposedly, the foliage acid, as we understand now, maybe will be another factors. Does not,
26:00
is not present, doesn't work for genetic or environmental factors, remains open Hey, when I was. in a bill in 2009, one of the conversations over there we had, whether the increase of neurotubed
26:19
effects in the Kurdistan region was a consequence of the chemical war that happened years prior to that. So when you have a defect
26:36
of the neurotubed, you will have a defect on the closing in many, many levels of the body.
26:43
You see this child with an open mouth.
26:47
He's MRI is on top in here and he had an encephalosceling. A part of the tube that these things supposed to be are round closing here, didn't close well. And a sacrocerevospina fluid went on. how
27:07
this patient was diagnosed, it was diagnosed because he had repeated pneumococcal
27:15
meningitis. Of course, there was a very, very tiny layer of skin and the pneumococcal from the mouth kept on spreading into his body and treated and treated until finally a very astute pediatrician
27:32
said open the mouth, open the mouth and there wasn't several celli. And you see here other children mostly from the China where I went many times, they have different areas of defect of
27:50
the neuro tube can be frontal, can be sphenoidal, can be parietal, can be occipital and you see the MRIs that explain that. The common one is this one,
28:05
the myelomeningocellus. one on the bottom of the right, in case you don't see it at the cursor. The most common one in Iraq and everyone in the world, but the other ones are also present. And if
28:19
you read that the paper of your
28:22
colleagues from Al-Diwaji province, and I keep mispronouncing the name, I apologize,
28:31
they say which type of neural tube defects those children have.
28:39
So this is certain neural tube defect. You have a tube that is formed by the day 20. When barely our parents knew that we were coming, we already had a tube form. The crucial thing of the forming
28:55
of the tube is the closing. If the tube is not closed, there is a leakage. A leakage is the way of saying there is an extrusion, there is anurnia of tissue.
29:07
outside that can create different neurological problems. And we will not go to that in this moment, what I want to see is the conceptual thing. And the myeloma ningocellae is the most prevalent.
29:22
We'll talk about myeloma ningocellae now. The child on the left is a child I treated when I was in Mexico, the statue on the right is an all make a pre-Columbian statue. As you can see, they all
29:39
make us hat also children with spina bifida. And you can see that
29:46
the lake
29:48
of the piece of art is really not robustly formed. The first drawings of myeloma ningocellae per se that you can see over there in here underneath were done by Dr. Tulk. Dr. Tulk.
30:06
besides being a good drawer
30:10
is the famous character on the anatomy lesson by the Rembrandt. The main reason I point into this is just saying, myeloma ningoscellus, pina bifida, neurotubed effects are there everywhere and in
30:28
every century.
30:31
So this is the myeloma ningoscellus. These are three different cases.
30:36
If you see this cursor here, you see
30:41
a black line. This is actually the center of the neurotubed and the two red images on the side. Particular here you also see, but this is the best study. The two red images on the side are what
30:57
you saw in the drawing, those when the bulging of the walls and
31:03
they failed to hit it close. very well. You can see this in work. And the level of damage is represented over there. Depends at what level the spinal cord is injured. If the spinal cord is
31:21
injured at a very low level and five for S1, then will be sphinter problem and minor mobility problem. It is much higher the besides the sphinter problem that is a must in every myelomeningocelli,
31:38
that the
31:40
child will have an imperfect embolation, motor and sensor, you know, for obvious reasons. But what you see here was the failure of the closure of the on the cord is, you know. So this has been
31:55
anterior, this has been superior on top, this is like the, like the child looks, I will try to go quickly here. So you see when you put a drop and then I construct. you see the line in the
32:08
center, which is the cube that failed to actually fall. And then you start cutting the, freeing the, the, the cord
32:26
from this aradnoid adhesion, and let me see over there here. Well, I will go slightly past it in here And this is the spinal cord that doesn't have the shape of the spinal cord, because it's like
32:39
an open sausage. Here on top, if you can see my decorcer, you see the ceiling there of the normal cord, a ceiling there, right? Like a tube. That part of the cord close. This part of the cord,
32:57
leaving close. It's open. And that,
33:04
you see part of the good cord, This is the duramata, and this is when the lesion has been dissected and been down. And then you create a plane of dura to
33:21
close over the defect. You see, this is dura, this is dura here, and you close the defect to prevent the exposure. You basically are repairing the wood The reason I show this is because it
33:36
clearly emphasizes what is a neurotubed effect. A neurotubed effect is precisely the system in which the tube failed to close, failed to close, most likely because of a problem of falling cancer
33:58
Here we are putting a patch of urine to future the effect.
34:06
So,
34:09
let me see if there is anything from the,
34:14
no, no, perfect. I was just checking on the chart, if there was something pending. So, the big question is, why this thing happens? There are associations that I don't believe them very much,
34:28
and I mentioned them just for intellectual honesty, no? Age, poverty, obesity, maternal illness, hot, hot cube use, come on. Anti-cision medicine, yes.
34:47
What is clear is that image that you see on the right in here, that there is like a line in countries who are
34:60
well-industrialized, The population is adequately fed. those countries to the left of this line usually have less incidence of neurotubule fat, or spina bifida in this case. Countries who are like
35:12
Africa, Asia, many areas of Latin America, the incidence increases. The idea was, is the least that polycosid ingestion that polycosid ingestion, taking polycosid before pregnancy, is useful,
35:12
makes a difference. The interesting thing, you see that lady smiling, the lady from Guatemala smiling there. Guatemala had a very high incidence in
35:55
one time. It had one birth every 600. Imagine every 600 birth, one huge in this. You in Iraq have. 1, 000.
36:09
So that was one every 600. So people decided to fortify with fallic acid the flower with with which the people made the decay, the tortilla.
36:24
Massive fortification, lots of money from
36:30
the WHO. All the tons of flowers were fortified. The incidents did not decrease, the same.
36:38
So what was the issue? There was a fungi in the corn that prevented the action of the fallic acid.
36:49
So that led to people asking that they washed the corn that is
36:59
grading now, that they washed that corn with leech. Of course, it didn't work.
37:06
But the emphasis of this is to show you the complexity of the problem,
37:15
the attention that is paid to the problem, because children born with neurotubed effects, with spinal bifida, fortunately, the mortality is very low, but the quality of life is really impaired by
37:35
the motor and sensory problems, and sometimes also by the intellectual development, and that is an anchor in the whole family. We have to find a way to prevent this condition, and when the
37:51
condition is there, we have to find a way to treat it in a better way
37:57
And you see what the problem is. You see in this paper from the epidemiology of neurotic defects in Saudi Arabia that we discussed last time. here,
38:08
last year, last year, last lecture, you see, there is a group of people that say followed acid administered during the first semester. And conceptually, you already know by looking at the movie
38:23
that the cube is closed, already closed
38:31
much before the first 30 days So taking fallic acid in the second semester or in the second months of the first semester is completely useless because as you can see here in the in the film by day 21,
38:54
the tube starts closing.
38:57
By day 25, for sure, the tube is already
39:05
So there's no point in administering folic acid in the first remester. And this is what they
39:15
call it from Saudi Arabia, also found.
39:22
Other problem is the late closure, other problem that you can do for your future clinical research if you want to do research. So this is a newborn with a spinal bifida There is still normal tissue,
39:37
I mean, tissue, affected tissue, not normal tissue. But what happened when the, if the child comes two or three weeks after birth, there is granulation on top of the
39:51
anti-spinal court.
39:54
Does this affect the neurological development of the child? Yes or no? We don't know. There is a subject of research for you.
40:05
you just can look at the level of which the spinal cord is damaged. Say, for example, it could be L3L4, okay. So this child will have L3L4 down in pair
40:19
L2 up normal.
40:23
But if this child on the right side who also has an L3L4 will have the same neurological outcome
40:35
if he would have been operated and he or she would have been operated on the first week. We don't know that. Why we don't know that? Because in this part of the world, those children are operated
40:48
on the first day of birth, after birth, that transfer immediately to neurosurgical center and operate. In Guatemala, where I worked for many years, I was a visiting surgeon,
41:05
those kids come two, three, four months after.
41:09
And, but as I couldn't do the follow-up of the children, I came back always to the United States. So I don't know if the same level of vision revolts or causes, same neurological damage, whether
41:25
it's repaired at birth or repaired later in life My point is, you can see there, there is a subject for research.
41:39
And in your own faculty, medical school, in Baghdad, they report 147 cases in three years, that is 49 cases per year. 49 cases per year is four cases per month It's in a huge amount of cases.
42:05
And I praise immensely the
42:10
authors, Professor Alsace and
42:13
Abdulusseh for being so open and honest. And I think they are exaggerating. They just decided anything that is not perfect is a complication. I don't think they had that much complications as they
42:25
mentioned. But there you see, in your hospital, in your town, and this is the faculty of medicine, juvenile medical school, but that is published there. You are there. You have the subject
42:45
there to start a clinical research in a conceptual way. What's the concept is? The concept is, for example, in this case of complications, are the complications affecting the life of the child a
42:59
year after?
43:01
the complication is just a. And we sense, yes, and we sense, it's a problem. You have to operate again. You have to be funded by all the things. But what happened to the child? Does this thing
43:15
affect the child? And how can you explain with your knowledge of neuroanatomy and neurophysiology this conceptual question?
43:27
This is a fantastic paper and I send it to you anytime you want or you can find it by yourselves on the web, but
43:37
again, you see it's a fantastic paper I praise the authors, but the next step for you to do is to answer that the conceptual question. Conceptual question, if the neurosystem is to communicate,
43:51
how is the level of communication or the capacity for communication that those children have, does it make a difference, a complication?
44:03
which complication made a difference? Yes, no, sorry.
44:09
And the last thing, Tether Court is another issue related. If you look at the paper on complications, then mention Tether Court. But we have authors from Saudi Arabia, your neighbor in country
44:24
that you are who in report on this interesting phenomenon called Tether Court, 35 patients in seven years or five patients a year. That's a law. Five patients a year in one hospital, in one room,
44:41
in one town. Whoa, that's a law.
44:44
And
44:46
a phenomenon that they call Tether Court. What is the
44:52
conceptual
44:55
think of Tether Court. And this is the three slides I added. That's why you had a new the earth. When we were born in
45:08
our hip and our head, they were close. We were babies, right? Remember that spinal cord is attached, it's part of the brain, it's not a separate entity. As we were growing, as the thickness
45:25
and the width
45:28
of the vertebra increased, our torso increased in size. And we were moving up, our head is far away from our hips, right? I'm not talking about the length of the lips, I'm talking about the
45:44
length of the torso. And as I consequence, this spinal cord moves up.
45:52
That's why when you do a lumbar puncture in a newborn baby, think about this, not like an adult In an adult, you can do a number punch on a level L3. L4 or L4,
46:07
L5 without any problem. There's no spinal cord there. But in a baby, be very careful because the cord is there. You can punch on the baby, punch on the actual cord because it's in law. So if
46:18
that movement growing up,
46:24
his tether is anchored, he's impeded by something, the cord stretches, the cord suffers and the patient has symptoms of a spinal cord damage.
46:38
So there are three forms of tether cord. One, the thick phylum terminally, you will see a movie about that. The spinal lipoma
46:48
or the myelomeningocellular, remember when you are closing the myelomeningocellular, you are closing and the fresh cord is attached to the fresh tissue that creates a scar.
47:01
and this creation of
47:04
the scar encores the
47:07
spinal cord.
47:10
So the conception, yes, that word, the conceptual pathogenesis is that you have a traction. This was done in a cat. This is the spinal cord of a cat. They put a weight on the end of the phylum
47:26
terminally and they were increasing the weight So that the poor cat or cats had
47:33
the parador stretch and stretch and stretch and yes, of course they suffer because there is a decrease in the red or spotension, the decrease in the blood flow, and there is a decrease in glucose
47:47
uptake. And this is what they call it in Saudi Arabia at least in five patients per year, but actually seen And this is what you may see in every patient who had a myeloma nigga cell A. operated
48:02
because of the tethering of the of the court, but you come to this idea. So those conceptions, if you have a concept of what a court is, so next time you go to a ward, a pediatric neurosurgery
48:16
ward, you start seeing that the whole picture, that the whole pronoun, you understand that the concept, like the America was pushing. So this is a tether court after a myeloma ningocella, sort
48:29
of move the MRI, you see, this is the MRI there, and there it is, that the scar created of the closure, you see, the
48:41
myeloma ningocella is there, it was closed, properly closed, this is skin on top, but there is a scar because of the future of the era that
48:54
you saw in the film, just a few slides before. This is a lipoma.
49:01
you have seen kids like that, I'm sure. This is the Mariah of a lipoma. You see that the court, this spinal cord, by this time, this spinal cord is already in L5 and four, and this is an older
49:15
child, should have been much higher. And the picture from the surgery, you see here is the lipoma already reduced, and here is the spinal cord underneath So this lipoma was adhered to the skin and
49:34
was tethered in
49:38
the cord, creating cord damage. Spinabifida occulta,
49:45
you will see for sure, that kid that has a tuff of hair over there with a small dimple, or a small dimple in there, and I just, this is, the spinabifida occulta is a problem. Remember that the
49:57
blue line, that the skin and the nervous system. came from the same layer. Well, there has to be a separation of those layers that sometimes fails. And you have a spina bifida occultus,
50:11
something tethered in
50:14
the chord over there. And here, this is a very rare case, but that's the idea. You see, Akit, this was in South Africa. He had a bumpy, a puff of air Remember, hair paths in the middle, hair,
50:32
skin, vermato, nervous, midline. Think of the animation that you saw a couple of times already. And this kid had a burning bony spher that the thought is not perfect. And you see, once we
50:50
remove the bony spher, it's one part of the chord here, the other part of the chord in there There was this burning spell that was tethered in there at the core. You get the concept, just this is
51:03
for the amusement of the red. And then another one that our colleagues from Saudi Arabia mentioned, the thickened phylum terminally. You remember the phylum terminally is the extension of the court.
51:17
Sometimes that phylum terminally is thick and doesn't allow the court to move up and down.
51:26
When you bend UI, when anybody bends to touch their toes or lose some exercise, our court slides inside of the canal. But if you have a thickened phylum terminally, it won't slide. Then you keep
51:41
on bending and then you keep on damaging. And one day, you may have may or may not have a problem. In this surgery, you will see how we find the phylum terminally. And when we divide it, the
51:55
phylum terminally disappears from the.
51:59
Ah! from the surgical field because it is under tension. So this is a L5S1, this is the neuromatter. Those are the nerve roots.
52:14
Those are the nerve roots. And then, I think it's me holding this, that we identify as the fundamental.
52:25
We stimulate just to be sure it's not a nervous system And then the resident, you see how it's shaking the hands, that's because it's the resident, grows and cuts the thing,
52:38
tries to cut, tries to cut the phylum, cuts
52:41
the gun and the phylum disappears, was a phylum, a thicken phylum, terminally, which is not an issue described by Lazarus in
52:52
the United States, talking in a Zoom conference to medical students from that, is in the paper from there. from the colleagues from Saudi Arabia. They had like seven of those cases. So at the
53:07
point being again, Tetercor syndrome, a study of 35 patients.
53:14
Fantastic study, I praised the daughters, but they didn't take this course and they don't explain. At the end they say, the study of the natural history of Tetercor syndrome showed that CCA then
53:27
the patients over two years of age develop progressive neurological deficits. Why two years?
53:38
What happens at two years that makes such an important rule? I don't know, is there a rule that I follow? As well, when I operated patients in here and I operated on the patient that you saw,
53:54
This is part of my own cases for many years ago, but why two years? explain.
54:02
And that is the test for you as a clinical future body clinical neuroscientist. Yes, you will be asked to go from one lab to another lab to bring up to bed to do the same to measure that. But when
54:18
you are free of that, sit down and think, How can I explain? Explain is the issue.
54:27
This is one of my patients in Guatemala, and I made it as a symbol over there. Okay, you can see the globe, meaning this everywhere. You can see Guatemala was a tremendous problem, but what is
54:40
important? See the child.
54:44
The child already, he doesn't have a myeloma negatively, he had a lipoma. You can see his feet are already damaged, but it's less than two years It's less than a day, two years.
55:01
you can see its feet is already done like that small feet, you know, so what is happening? Why is it two years? I don't know. I don't have the answer. I just want to installing you the the
55:14
curiosity if possible to answer those those are the questions in a conceptual fashion.
55:23
And there are plenty of evidence in your country, in your region, but just some are Saudi Arabia, but in your country as well, that those things are there. There are a problem for the population
55:36
that you, for your compatriots. This is a clinical problem for them, believe me. And if you can solve for begin or raise the interest in the minister of hell, whatever, and we need to pay
55:51
attention to those things,
55:53
maybe you will be the
55:57
I am sure that in the 40 of you, 39 of you that have been so steadily following, I'm sure that a great majority would be brilliant because you need to be brilliant to be listening to me and so, so
56:11
late in Baghdad, you
56:13
know. Anyway, with this with, we just finished and as I said, and I repeat for those who may have arrived later On Friday, we will go, I will make an 45 minutes presentation about one case that
56:26
summarizes everything is medical medical ethical
56:32
I, maybe I will mention here, but then once we finish with a lecture, I will deeply appreciate and Professor House also will deeply appreciate if you share your thoughts with us. Prepare your
56:51
thoughts.
56:56
How can we do, how can we improve and what the things that were positive for you in this series of seven letters that will be next week?
57:11
Yes, we already have the site, a surgical neurology digital They just want to review quickly the videos, just in case some Antoine, one thing, there's nothing in the individuals to be worried
57:29
about, but yes, all the series of letters will be uploaded and you will have direct access to them to go back and review and you have the
57:46
PDFs and now that we are coming to an end is then that I can start writing a text because I understand where we went. we arrived, I had a different plan in the beginning and through the letters of
58:00
some of you, I was changing a little bit. Some of you wrote me and asked me questions and then so I changed those accordingly. But yes, you will have a text. Yes, you will have the answers to
58:16
the video And yes,
58:20
we'll see you in the slide. And now I am open for questions.
58:30
First of all, I want to thank you, Dr. Lazar, for this nice informative. I just want to have some comments before seeing if more questions are there. First, I want to say that even as an
58:46
neurosurgeon practicing in the Middle East, I didn't know about the incidents that much for It's an eye-opening for me and
59:00
I don't know the paper from
59:04
Duaneer and from Baghdad, actually the one from Baghdad is from the Dean of the University of Baghdad and the one from Saudi Arabia. I think I'm not aware at all that the magnitude of the problem,
59:22
this number one. Number two, I think I just want to confirm your message to the student that yeah you can start to think about solution for this real problem and I think one of the impacts that the
59:41
example of the philosophy said that there is a lot of way to save lives and this is what you are doing now to explore more about them. medical option, the diseases to understand what you can do for
59:58
as part of your future how to help patients. So helping patients is a common understanding, but how you can do it. I think for people understand the explanation for today and the example,
1:00:13
Professor Lazarov said, this is a real challenge and if you can't change the life of those patients, you will change the life obviously for their family and even they are not a fatal diseases like a
1:00:32
direct fatal disease, but those are obviously devastating. I think not all medical students understand how much you have and I think it's part of our responsibility that if such disease has approved
1:00:49
today, It's already available in our cities, so it's part of our duty to think of solutions through research, and that will make things more valuable. That's it, that's my comment. Thank you,
1:01:06
Rosalo, thank you, thank you. Anybody has a question regarding this?
1:01:16
We already put in
1:01:19
the chat a question about which one from which city you can go, you can see it, Dr. Lazarf as well, just an idea about the cities. It's from inside Iraq and from UAE and from Saudi Arabia. You
1:01:35
can see it in the chat. Also, I will send it to you later. And I think Rania has a question. Here, Rania
1:01:47
Hello, Professor. Thank you for your presentation. I'm doing well. How are you?
1:01:53
Europe as usual your presentation was magnificent, especially when
1:02:05
you mentioned that pediatrician who discovered the presence of neural tube defect in the patient who had recurrent and injectus that was really inspiring for me.
1:02:11
I Have a question regarding neural tube defect Despite the great advancement. Are there any unresolved questions or challenges in the research field? And I'm by other words like what areas are
1:02:28
Researchers are focusing on currently in order to address those challenges and thank you. Yeah, and there are
1:02:38
And I am recording this and I say that the are
1:02:45
formed, the people who are not formed so well. what we call like any other humans rarely get too much attention. People focus more on the attention of tumors, cancers, and the effect and the
1:03:03
number of the incidence of the malform is huge. So the areas of the researcher are two. For clinical neurosurgery, precisely, and I think that we achieved that doing. You saw that child, Simpson
1:03:22
was the child's name, and I'm not giving her name as well. Simpson, that child, we structured with a neural patch in order to prevent the tethering of the of the cord. Now, with the idea that
1:03:39
the neural patch will not, we failed The
1:03:43
core tether we needed wanted to run many years after. So our idea didn't work. But the idea being, okay, how can we do things to prevent the complications from happening? But what we did with
1:03:58
many of our children, all our children have, and I didn't do as many as, because we don't see that many. We see three or four cases a year here in the United States.
1:04:11
For one reason, perhaps, folic acid, and for the other reason being abortion. Abortion is allowed here. So, when the child is found to be spina bifida, so, so when we see those numbers that
1:04:32
decrease on cases in the United States, Canada, Germany, we don't know how much is because of folic acid, and how much is because of other reasons
1:04:44
If you go to your cereal, do you have cereals in Iraq? as they have here in the United States, the cereal box,
1:04:53
if you have cereal box, I will take out a picture of one of the cereal boxes here, cereal boxes, huh? Yeah, we have cereal box. Okay, go and look to the cereal box. You will see there is
1:05:05
fallic acid there.
1:05:07
You will see that they put fallic acid in the cereal box, but they don't put in enough quantity. You really have to take three bowls of fallic acid to actually fulfill the thing But there is fallic
1:05:17
acid in the cereal box because of this, because of people trying to prevent check on the, it says fallic acid. Usually it's 200 nanograms or that should be 400. But that's fine. But
1:05:33
a way of doing surgically is you have a level of damage. Say, for example, L3, the
1:05:42
myelomeningose L is L3. Now, if you operate with a microstroke, If you have the senior surgeon operating, if you really take careful care of the spinal cord, maybe, and it's happened, we have
1:05:58
seen that happening, that the level of
1:06:05
damage goes down. So what was an L4 ends up being an L5
1:06:11
because you took care of that thing Why we didn't publish that, or I didn't publish, and many others didn't publish because this sounds like a bragging, no? Look, I took out 20 patients with this
1:06:25
demo damage, I operated on the patient, and the patient is one degree better, that's. But that's an interesting way on the other side, on the complication. So if you say a complication is not
1:06:41
only a couple of days, It's trying the hospital and more money or it'll is money. complication is a child who cannot go to school or cannot finish. There are children with Mala Menicoselli who are
1:06:55
furthermore, as a
1:06:59
homework, go and check the chairwoman
1:07:07
of neurosurgery of Ann Arbor, an Ann Arbor in Michigan, an important hospital in Ann Arbor, Michigan. The head of neurosurgery is Dr. Marescu, who was born with a Mala Menicoselli. She goes
1:07:26
with one of those juniors on there, you know, and they lower the table, the process she saw.
1:07:35
So you can have
1:07:44
a normal development, but it's an interesting question, why Dr. Marescu had a normal development. If we know that the neural tube and the neurons start from the center and they migrate and she
1:07:50
became neurosurgeon, a chair of neurosurgery. And then other teeth, similar way far, cannot go through third grade. Why is that?
1:08:03
So there are many areas of research for you in the moment. And the big research, of course, is how can we prevent this from naturally happening? Prevent through pills or not, or something, no?
1:08:22
And why did the thing close? Imagine this is a magnificent
1:08:31
piece of magic trick. You have something open there, and then starts folding, folding, folding, closes and foam, and you have a brain. Wow, what's that, you know?
1:08:45
I hope I answered your question, Rania, but I always talk a lot, you know. No, Doctor, thank you very much. I really appreciate it. Thank you. Thank you. A question, thank you so much for
1:08:56
the representative lecture, that's all. I actually was wondering through the lecture about what would be the possible changes or like contributions that can be done by us as a medical student to
1:09:06
help in solving such a problem. I mean, is there anything we can do in this stage as a medical student? Yes, when you
1:09:19
go to the hospital, just start making a record on your own, say you see at a patient with different forms of neurotic defects, and then safely and safe anoselli, you will see them as you can see
1:09:32
there are many there, no?
1:09:34
And then if possible, respectfully, asking permission to the mother, you all have a phone, take a picture just of the lesion, not of the face of nothing. Make a note, this is a Legion L3, L4,
1:09:50
L5, politely asked what type of Legion is happening. And I say as a medical student because you have to study, you have to work, you have to prepare for your exams, you have to sit like that. So
1:10:02
in that way, you say you will collect 10, 12, or five, or three patients. And then you go and ask them, and contact the family a year from now, a year after that time, and then see what
1:10:16
happened to the child. And then follow the story of the child. This is as a medical student, no? I mean, because you have 97 things to do. Just follow, if you follow two, three, four of those
1:10:32
patients
1:10:35
will be incredible And some are went off of the, but Yeah, I used to. Thank you so much, Dr. I guess. No, but did you receive, is it not just so I eat a repeat, I say?
1:10:49
No, I get, I got it. And you actually got it. Take a picture from the family, and ask that the family permission to contact them a year from now. You will see, you will have five or six
1:11:00
patients, natural history of spina bifida in your country, in Iraq. That is a paper worth for the journal of neurosurgery.
1:11:15
Yeah, that's great, thank you so much. Thank you so much. And then the story of the independence, Mr. and Mrs. So on. So tell me this, does their problem, a narrative history? That would be,
1:11:27
absolutely.
1:11:30
All right, thank you so
1:11:35
much. Dr. Lazarfel, before the end, I just want to add also another option
1:11:42
today by your lecture is that most of the
1:11:47
local hospitals have some records already. So maybe the student can ask the department, I can collaborate with all the students whether an error or outside. Absolutely. Yes. You understand that
1:12:04
for general neurosurgeon they are doing definitely neurocubed effect But if we reach to them and we will tell them that we are interested to build a series from this hospital about neuroto defect, he
1:12:23
will be happy, the student, and that surgeon will be in the authors and we will have your supervision at least to develop some local records if we succeed in a few hours. that will be a good thing
1:12:41
that at least we have some series from some of the hospitals to know what we already have and then there may be a regional difference as you say there may be cultural, environmental, whatever
1:12:59
factors and which can be studied later in another studies Yes, absolutely that's a yes absolutely absolutely then you can go and then you even can from the series of patients that you collect I am
1:13:16
obsessed with his personal history. Maybe if you write a letter or what is the most appropriate polite manner of asking and seeing what happened or if the patients come back every month or so or
1:13:29
every year for some form of cleaning And what is happening to those patients and what the families are actually having. Yes, you are absolutely right growing bad. asking the collaboration of the
1:13:40
general surgeons who take care will be outstanding, yes, absolutely. Yeah, they can go one way, at least in Iraq, I think in UAE or in Saudi Arabia, there are no developed record, but in Iraq,
1:13:54
the only way that we can do that is we go to the neurosurgery department, having the cases, and then we go to the records, having the phone number and the student can call the patient one by one to
1:14:08
understand the follow-up and the outcome. This is how we do, at least for our vascular cases, we can do the same for this category of patient. Absolutely, an idea, and then you may also see how
1:14:22
many of those myeloma ningosellis at Twitter court, how many they suffer from the Twitter court, I mean, it is amazing, I mean, yes, absolutely the colleagues from Saudi Arabia who and describe
1:14:38
the tethered cors syndrome, they had some few with myelomeningocelli. But compared to the number of myelomeningocellis they have in their country, they only report seven myelomeningocellis. So
1:14:49
come on, only seven out of the hundreds of cases. That may be a misdiagnosis. And we may not be helping through your fantastic work to cure the disease, but we will improve the quality of life.
1:15:09
Yeah, definitely.
1:15:12
Okay, then. So
1:15:18
I just want to say that for people,
1:15:25
like if you are the surgeon or if you are the doctor responsible for telling the family that they will have
1:15:34
myelomeningocellis and their child will be paralyzed. for life, potentially, that's very, very tough time. And once you face this situation, you'll understand most of them, at least in our
1:15:51
culture, they would prefer that to tell them that their child is dead, rather than to say they will be paralyzed for life. And this is how we're devastating for the families, is it, in addition
1:16:05
to the patients So yeah, I think that's just, I want to tell the student about that, because they may not realize initially the impact of such disease. Yeah, often happens. And I'm sure happens
1:16:20
the same because in this study that we showed last week and repeated today, again, from Saudi Arabia, they say that the problem of misdiagnosis of the ultrasound, Now, the technicians do not.
1:16:34
that technicians just do technicians or physicians, do the ultrasound just to see where is the placenta and that the heart is beating without focusing on the diagnosis. Many times here was a common
1:16:49
thing of the family who just discovered that the child had a male meningoselli, so they have a conversation with a neo-nautologist and a pediatric neurosurgeon about what the possibilities of the
1:17:03
outcomes are and all those things. And it's a harrowing decision, as you're saying, yeah. Many times it will be absolutely, no, no, no, that's a highly understandable, and I will say that's
1:17:13
universal, no? Yeah, even if ethically challenging that those decisions, especially with the new advances, some people suggest the intra, what's your opinion just to have an idea for the student
1:17:29
as well about the entritron treatment of such cases. I know it's early, but what's your opinion? Yeah,
1:17:39
the intrauterine cases, they, I may address briefly that next week, they reduce the incidence of a carry type two malformation. They have some improvements in the spinal cord. The big, big issue
1:17:59
with the children with the teterchor syndrome or malovingoselli, of course, and lipoma are the sphincters, no? The functioning of the urinary and the retal sphincter, bladder and retum, no
1:18:18
functioning. That's, they, so there is sometimes motor improvement rarely with the sphincter. And in utero surgery has not improved so far, in the
1:18:32
cases of
1:18:34
improving on this finter. Also theoretically you are putting in the mother in danger as well. So, so far is a very imperfect thing and maybe we will be understanding better later, you know,
1:18:46
because by the time the issue is you see that the court is open, right? There is an open court That open court is chuffed by the amniotic fluid. So, it is already damaged. Yes, you may reduce
1:18:46
something, you may et cetera, all those things, but the court is open, it's there. You saw that the pictures of the newborn child, you know, and the other one, yes, is protected somehow from
1:18:46
a layer of arachnoid or granulose tissue sometimes But basically, that part of the court is not protected with the bone or the deura.
1:19:32
and the constant beating of the heartbeat impairs the dysfunction in of the court, no? But hopefully, in the raw one day, we'll watch only made some difference, no? I think that prevention,
1:19:47
understanding, and also understanding the rare cases I had in my career, I operated on the child, and then on the child's daughter, it was that child, became a 20-year-old woman, became
1:20:04
pregnant, there's no impediment from pregnancy,
1:20:09
and she was taking folic acid since birth, more and less, and still, their child had a myelomeningo study too, mother and daughter,
1:20:23
so there are issues that we still don't understand the neurodevelopment
1:20:28
Thank you. Thank you, sir.
1:20:31
Thank you, thank you. So, I'll be done for the day, yeah, no?
1:20:38
Perfect. Thank you. Thank you very much, all of you. And see you next Friday, and the videos are coming. Thank you.
1:20:49
We hope you enjoyed this presentation.
1:20:55
The material provided in this program is for informational purposes, and is not intended for use as diagnosis or treatment of a health problem, or as a substitute for consulting a licensed medical
1:21:10
professional.
1:21:15
Please fill out your evaluation of this video to help us improve our programming and for our application for CME Credit. This recorded session is available free on snidigitalorg.
1:21:33
Send your questions, comments, suggestions, and applications for CME Credit 2, ossmansnidigitalorg
1:21:46
The series of lectures is supported by the James I. and Carolyn, our Osmond Educational Foundation, owner of SNI and SNI Digital, and the Waymaster Corporation Producers of the Leading Gen, a
1:22:03
television series, silent majority speaks, role models, and the Medical News Network
1:22:21
Thank you
View Transcript
Listen to Podcast
