Welcome to the 15th SNI and SNI Digital Bagdad Neurosurgery Online Meeting held August 7th, 2022.

The meeting originator and coordinator is Samer Hoz of the Universities of Bagdad and Cincinnati

Today's lecture is Functional Neurosurgery in Iraq.

Today's lecture is

Hiba Abdulamir, neurosurgeon and trainer for the Arabic Board of Neurosurgery.

She is also at Dr. Saad Alwittri Neurosciences Hospital in Bagdad, Iraq

Today's lecture is 23 minutes.

The discussion session is 7 minutes.

There were more than 110 days of a day.

from 18 countries.

The video editors are Mustafa Ismail, College of Medicine, University of Baghdad, and Fatima Ayad, fourth year medical student from the University of Baghdad.

Everybody, you know, that functional neurosurgery, we can start with next, please.

What's from neurosurgery worldwide?

And a field divided into three major fields.

The structural neurosurgery

as vascular, scovays, the finals, something else.

Functional neurosurgery, that deal with the functional anatomy and the functional pathology of the body Be constructive neurosurgery as we know the new era of the brain-gate theory with the Prophecy of the Journal and what we are doing for

brain and machine connection by what we say be constructive neurosurgery.

Actually, it's limited, but it started.

I hope it will get more improvement in the future.

Next.

I would like to start in functional neurosurgery in Iraq The first slide is showing the functional reduced surgery.

about four gamma-knife devices to icon and two perfection models.

The number of patients done from 2016 to now are more than 6, 000 cases treated by gamma knife.

It's used for usual neurosurgical indications and for functional indications like

etriginal neuralgia, glossopharyngeal neuralgia, epoxy, medial temporal secularosis, and jolastic epilepsy, also for fibromyalgia we used hypophysic tummy.

Next the structural functional neurosurgery done in our center by callosetomy for epilepsy temporal lobectomy also for epilepsy and VD for trigeminal neuralgia and for hemifacial spasm, also for selective dorsal rhizotomy for spasticity Next now we'll go for the important chapter which is a neural modulation and functional neurosurgery

First chapter I will.

about the vagal nervous stimulation in Iraq for epilepsy control.

There is a committee of three epileptogenic neurologists agree for implantation of device and in Iraq we have more than 400 implants

of vagal nervous stimulation with very good results.

The second one I will talk about spinal cord stimulation.

We have it for pain management.

We didn't start it yet for movement as we have a few centers on the wall that start using this spinal cord stimulation with high frequency in the programming for movement enhancement of course with the second feeling of movement, new feeling of movement for the patient but it started with the course of three months of physiotherapy that started doing movement spinal cord stimulation for movement enhancement.

In Iraq we know that some patients with motor improvement and others with even sphenics area control.

The case is totally about 300 implants.

Now we go for sacral nervous stimulation in ERAC.

Sacral neuromodulation, it's important for a boractivobladder as

we know for urinary retention, next, for also for chronic fecal incontinence.

Next one, we have this view of the S1, S2, and we'll

go for the S2 targeting the sacral nervous reef.

We can go rapidly for this view, because many of us know the technique for implantation of the sacral nervous stimulation.

And in summary,

the conditions of overactive blood syndrome, we notice that it's the most important and the most beneficial for patients with sacral nervous stimulation.

In ERAC now, we have around 100 patients with sacral nervous stimulation therapy.

We can move more

if we can do next please.

Next or next?

Next.

That's the procedure of implantation.

We all know that.

Next.

And I talked about the summary.

We are really happy with overactive with letters and drums.

Now we will move to intrathecal pump therapy for spasticity and for pain.

For spasticity we use battery of pain.

We all know that spasticity is a loss of inhibition of motor neurons causing excessive velocity dependence muscle contraction

and why we are using GABA receptors econist by bacluafen and trothically.

The prevalence is really high in Iraq and spasticity because it's about 80 in Cp patients and cerebral palsy patients and also we have a lot of war victims with spinal cord injury and that makes a really need for bacluafen pumps.

Next please.

Our own medication we used before was baccalaureate,

benzodiazepine, dantronins, garpapentins, but when using the pump we are using only the baccalaureate.

Next please.

We are using botulinum toxin, routinely for all patients with spasticity and patients with dystonia also get benefit from a botulinum toxin injection.

Next one, next slide.

It is talking about intratical baccalaureate and SDR

for patients with spasticity.

I can go directly.

What happens during surgery?

We are preparing the patient, placing the catheter.

Which slide do you want to have?

To the photos please.

This one okay.

Yes. Mm hmm.

This is the full system of the Baccala Fium-Pum.

It's an intractic called Cathitor Insertion and intra abdominal reservoir, and connected by a tunneling catheter and it's dropping a drag as we want as morphine or baccala fin.

You can go for next all its

rapidly, all the photos

I'd like to save time for the videos.

This is the redoever.

Next, just next model.

Next photo photos.

And here what we are doing in programmer, it has a compact lot of fume pumps in Iraq about 500 patients with backloaf fume.

And

after that, I will talk about infusion pump for pain.

We are using it for cancer patients mainly.

And in Iraq, we have around hundreds of surgeries, 100 patients with more fume pumps.

Some of them die because we are using it as a palliative for cancer patients mainly.

But even for CRP, we are used, we used some more fume pumps.

If we can go directly to deeper brain stimulation summer, I will be thankful.

Which is.

Next Yeah

Yeah

Actually, I'll talk briefly about the deep brain stimulation on rapidly.

It's the point of passion for every functional neurosurgeon.

Next one is the history of DBS started from Sir Cooper and that was on 1952.

After he is incidentally cutting a coroidal artery and two coroidal arteries So the

patient after surgery was a tremor is subsided and also rigidity and no hemipares.

So he think that I did as a truck in the cinema, especially he think about the venom.

After that he used a whole foreign injection in a global salad.

And that things that developed over the time until the era of

binavid Sir Alain binavid, he is a French Algerian neurosurgeon and he uses.

the stereotactic and beginning of the DB brain stimulation.

And FDA

approved that in 2001 for LBS and STN. From that era, we are starting working with

DVS and what is that DVS? DVS stimulation is elitatron using a neural modulation connecting to intermittent pulse generator by an extension wire It's a minimally invasive technique.

Next, is there any other options rather than deep brain stimulation?

Yes, we have radio frequency, we have gamma knife, we have high-focused ultrasound, which is started nowadays.

And I think it started in America, it started in Israel with good results.

Also, do do do do do, mesencephalic fetal transplantation done, but I don't know about the results.

It's not such promising.

For DBS, as we know, it's motor fluctuation and movement disaltellations, especially in bark acid patients, the dyskinesia, medical refractory tremors, and patient-flow medical intolerance, which means drug side effects.

The DBS

workflow is the pre-frame MRI, the frame fixation, the poster frame, we're using the stereotactic imaging by CT on the

MRI, planning to target and industry the trajectory and operating the stage

After the work of law, we can see some photos about in our center we are using Lixal frame.

All the surgeries I'm doing and actually I'm old.

All that success for my mentor who supervising every surgery with me.

Step by step, Dr. Munir Hamas.

I will be thankful for him lifelong.

We are using a Lixal frame for all the surgeries and we're using the still the station, the Ministry of Health supplying us with only Meditronic so in Iraq we are using Meditronic deep brain stimulation.

It was previously active at PC and you know they are changing now to percept which is

the sensing one that can help us more in programming of the patient.

We can mix the imaging requirement It's a deep details.

Next.

Okay, should I go for

this?

Go ahead.

This is the station

we are using using the

pre surgical MRI and one day before surgery, then a day of surgery and we are using a CT scan with the frame, then make a fusion of both of them By T1 image, we can make the ACPC line and finding the midcomisular point, then go for anatomical localization.

We are using anatomical localization always for

posterior part of AEM because it is the sensory motor of subtynamic nucleus.

In our center, we are preferring subtynamic nucleus for Parkinson's patient, especially with all three symptoms of Parkinson's disease And if GPI also we are going for GPI for

anatomical localization, we are not.

using them.

You know, if you are functionally working, functional working, in neurosurgeons, we can go from midcomicura point in a three-dimensional 12 plus - minus four, we are making it two and then minus - plus four, we are going to the target of, for example, ACN in these readings.

But we are going to visualize the target directly just near to the ready nucleus.

We have a three-test line, MRI It's a good thing in our center.

We can go for photos of this summer.

And the photos you send it are within the presentation?

No, here.

No, here.

Just next

to everyone.

OK. Sorry.

Please.

This is the basal ganglion.

That's only the important anatomical landmark for the brain stimulation.

Here is a subthalemic nucleus.

We have not to touch the anterior thalamic I must because it will deal with the lending.

to make something abnormal with the patient behaviors.

Here we can see the red nuclei, which is the two round, deeply black color, just lateral above to it.

We have that sub-tynamic nucleos.

And the targeting is so easy for functional neuro-surgical work.

After that, next slide please -

That's the last This is photos from our planning.

Next.

Next please, next rapidly.

If you come, I will just.

from the intra-creator.

This is the stem block what we use.

This is the only bare hole that we will do for the patient.

So it's minimally invasive procedure.

This is the micro-targeting drive that we are using to insert the

elocate throat inside the sub-salamic

nucleus in a few millimeter accuracy.

Next, please.

Yeah, I'm doing this slide But there is a little bit delay between the serene and what you see.

Yes, sorry.

Yeah, that's OK. That's

the elocateur insertion.

We are putting a wire for checking

neurophysiology for the impedance and every part in the brain have its own wave in

the

neurophysiologic screen.

So we can check, verify our anatomical localization by neurophysiology company.

verification then the bioengineer gave us a stimulation with that micro targeting a little noise and the neurologist will be with me in the surgery actually that's before now we go for a sleep surgery we didn't need the neurologist now and he will check the response of rigidity and of tremor immediately intraoperatively that was before but as I learned from Kim Po-Shile Professor Kim Po-Shile even Professor Footi Kelly Footi they say it's good for a sleep surgery and it's okay for a sleep surgery only anatomical and neuro physiological localization as I said STN is the best for from our experience

actually some of you can go to the end of the presentation

only the numbers.

of the patient and it plays a work.

Yes. The numbers of the patient which is the slide 1, 2, 5.

Okay, sorry.

Slide 1, 2, 5.

Is that okay?

Yes. Number of patients already done in Iraq totally 230.

We have two periods, period A, which is

2009, where my mentors started with it, the B, which is starting from 2015 till now, which is containing 221

patients with deep brain stimulation.

They are between Parkinson's, between this Tonya.

We did turret syndrome one.

We did one hunting times Korea because he was, she presented early in age and we are planning to do some new extends of indication Now we'll go for the places in Iraq, that's where we are doing the surgeries.

It's on the slide one, it's three off.

Okay.

Okay.

In my center in neuroscience hospital, we did a totally of 170 patients.

Also, we extend the work to the Sino hospital, which is in Baghdad in your surgery hospital, which is also in Baghdad, also to the south of Iraq in Al-Bassra, and at the topmost north of Iraq and Azulaymani.

Okay.

So we are expanding the work.

We are training the

neurosurgeons on the Congo.

The slide one is V5. I just want to show that man that I really respect him.

He's a famous artist and Hollywood artist.

Michael J. Fox who found a foundation, a big foundation in Canada.

And

we connect with him and a lot of researchers he found by his

foundation.

You can go for the other videos please, Sambar.

The external videos?

Yeah, please.

From our work, I will show you some videos for the patients.

And some photos for MVD cases because as we consider microbuscular decompression as functional surgeries.

Okay.

This one the first.

Yes, this is the first one

So this is a pre-op.

It's okay for this one also.

This full video.

Here's a patient with Parkinson's disease, sapsamam, we can hear clear bilaterally and started for him with active PC. Intermittent pulse generator and after programming you can see the video.

Actually, it's not such obvious for my sacrine.

Is it okay with you all?

Yeah, I think it's clear.

Okay.

We can notice this tremor

of Parkinson's patients and after making the

battery on, we can program the patient until it's subsided The best thing in the neuromodulation that we can regulate all symptoms over the time, not lightly, because when we do lesioning, we just make a cut of time.

We do this results only.

But for the neuromodulation, we all know Parkinson's is a regressive disease.

So with time, we can't change.

Please make this video.

So this is the next patient we are seeing.

Yes We have a rigid CT tremor and even tongue-get tremor, Parkinson's patient, primary Parkinson's

is a very good candidate for deep brain stimulation.

And I have this, yes,

that's post-operative

walk.

You can see he's moving normally.

He has handy swings, unstable gate And he's moving normally outside.

The

best thing in deep brain stimulation is a very good selection by a good neurologist, movement disorder, neurologist, and precise targeting and a good programming after the surgery.

So it's teamwork.

I think that's the last patient, Pre-O.

Yeah.

Can we show the same officials as a patient?

Yeah, this is the impression.

This is the preoperative one.

We use it by micro scope not by endoscope.

You can show the face of the safter

He has some sort of sound.

Well, wonderful results.

Wonderful results.

And you can show the after the last video

Here the thing is stable after surgery, about some days after surgery, this video.

As we know it's not immediate results with hemiphyseal spas and long time patients.

After 10 days, he's stable

I'm sorry for technical errors that came and I think it's okay for that.

If we can talk about DBS, I will talk some morning.

Thank you.

Thank you, actually.

Thank you.

And we are sorry for the technical issues and maybe sorry for the delay.

I'm not very professional in this

I would thank you again for that.

And I will start with Dr. Ossovari if you have any comment.

Yeah, that was a.

That was a great overview of all of functional neurosurgery.

So that's very impressive that you were able to summarize the totality of functional neurosurgery like that in one presentation.

And it sounds like, you know, I think obviously we're biased as functional neurosurgeons, but in my opinion, my humble opinion, I think functional neurosurgery is the epitome of combining technology science and surgery.

And the fact that you're doing it at the highest level, it says something.

And basically

I see no difference between really how you're doing and how we're doing.

I mean, you're just up there

following exactly the standards that have already been, you know, set worldwide.

So I think you're performing functional neurosurgery at the highest level of the profession, which is, you know, it's great to see that.

And in terms of your cases, I had a few questions.

the DVS cases you're doing are those awake or asleep -

Before we start with awake cases, and then first part awake, and the second part with IPG with plantation, I make them under GA. Now, no, we are going for a sleep, totally a sleep surgery, which is actually less time and such accurate, like awake - Yeah, and for the sleep cases, what do you use for your intraoperative imaging -

CR - Yeah - Okay, so you're using fluoroscopy, very good -

VIA floruses could be angi-no, while engineering, drawing

the cannula for me and the arc of the leksel frame on them, but lead is inserted exactly on the place -

Very good, yeah.

I think, and in terms of the targeting, are you using microelectro-recording for all of your cases

I'm using microelectroelectrode recording and it's important.

I think I can't ignore this step till now - Yeah, especially for a sleeve, right?

I think

microelectrode recordings is critical.

We actually migrated away from using microelectrode recordings for VIM, for essential tremor.

So we still use it for, we do all our cases awake and we use microelectrode recording for GPI and STN. But in cases of essential tremor, I've stopped using microelectrode recordings and just awake testing.

So I think, and that's just, yeah, that's just at our center.

I think if you look at other centers worldwide, there's a mixture of some people are still using extensive microelectrode recordings for essential tremor and others are doing it completely asleep such as Dr. Burchill.

that you mentioned - Yeah, Dr. Portiault.

And you know, we have only one case of Robros final trimmer after road traffic accidents.

We make it as, you know, this double targets for passing from STN to Zoom and something like that.

But also we are using micro-electric recording for both sides - Yeah, another, yeah - Yeah, another thing, I mean, I mean - Right.

Yeah, I think another approach for those rubral trimmers also VOA, simultaneous VOA and VIM stimulation is another approach that people have described in the literature -

But we didn't adhere -

Yeah, that type of trimmer is very difficult to treat in general, I find.

But yeah, I think this is really - We have

low number of rubros final trimmer So I think it was good with the double target thing.

Yeah, and I noticed you have a lot of Parkinson's patients, but not a lot of essential tremor patients.

Is that just a difference in the demographic in Iraq?

Actually, we have about 8 of population with Parkinson's.

So it's the highest in movement disorder.

And all patients

waiting lists about 1, 500 cases waiting for the brain stimulation devices, because it's totally free for the patient.

It's governmental supply.

So we have to wait for that.

And about 70 to

75 of them are Parkinson's patients.

The others are

you know, dystonic patients.

And even we are working with secondary dystonia.

Even I don't know, it's a good result.

So it's a canary sometimes.

And the Tourette syndrome, one patient of

patients with hunting cones and one patients with rapprospinal tremor.

The mass is parking some patients.

What about pediatric dystonia patients?

We didn't start it yet.

All dystonia we are doing for adult

dystonia.

Very impressive the time you're building there How does it take to understand the job?

I asked one question from Dr. Heba.

Why do they have such a high number of parkes zone?

Because they did a study in California that the pair areas which were given the poisons for the pesticides, those country people, they were all affected

with parkes zone.

This is one study I know.

So maybe somebody should look at the thing because it's a a very high number of Parkinson's.

That's according to Dr. Hibok.

Maybe somebody to look at that one to see what is the reason they have so much the non-logic disorder over there with some exposure to some chemicals or something -

Actually, as you know, Dr. Parkinson's disease, it's something related to the topaminergic close.

And all we are dealing with now are primary Parkinson's.

So it's primary cause at topaminergic close.

So it's Parkinson's first day about the cause of Parkinson's disease.

A little are familiar, but the majority are idiopatic.

We are happy to look for the cause - I think that's something to think of.

Maybe the last comment, there is Alcother, Aura from UCLA.

What's your opinion today?

Just to close with these a few comments from the students Because that's also important

So, Arra, do you have things in mind?

What's your appreciation?

Or how do you find this for you as a student - It was amazing to be here today, honestly a little overwhelming with all the information that I am receiving, but it's great that I'm just able to be here and learn from so many amazing individuals who are doing a lot of good work, good and hard work in this field.

And I'm really excited to continue to learn and to just

have such amazing mentors in my life.

So thank you -

Thank you.

Acting, do you have a comment?

And please present to you, and to introduce yourself - Yeah, first of all, thank you to all the professors, to all the speakers today, it was very inspirational.

Amakka Masama, I'm a

fresh graduate from Baghdad, Iraq.

I've given some presentations for cases in previous SI meetings, but

today was something next level if I might say so.

The presentations were very inspiring.

I think we learned a lot about

neurosurgery and innovation from the USA, but at the same time from our country.

So that was a very special moment for us I think.

So thanks to all the speakers.

I think that's something to think of.

Maybe there's a comment.

There is Alcother.

Alcother is a Iraqi medical student now studying in I think Osbick's time.

Also with us from.

Other patients.

Sorry, I'm sorry.

So yeah, introduce yourself and if you have any comment, thank you.

Hello professors, doctors and students.

I am Alcother.

medical students at the Zebejama University.

After I think this meeting was like a time machine because we started from the history of Neurasej or Naira, which is the past, and then we discussed everything about the future.

The instruments, the researchers and the obvious ideas, it's actually greatness in three hours.

So thank you, thank you for everything

And thank you for participation for all.

If anyone have any comments, we can collaborate also in the next meeting.

I think that this is a take extra time maybe because it's the first time setting in this setting, but I think each talk, each presentation deserves to have its time and have this discussion.

And yeah, what I have in mind now, I'm thankful for everybody for spending that time with us and yeah I hope.

we will collaborate in the future for next.

We are definitely open for suggestions about the design of next meetings and the direction and even for speakers, if you have anything in mind that you can put on the next meetings, we are more than happy to do that.

So I will,

it's the program end from my side.

I will leave the mic to Dr.

Osman to conclude and thank you - It's one o'clock in the morning and we thank you all for coming and hopefully you can give Sam or some feedback on what you thought about this.

And I've already seen a number of the comments and we appreciate it.

Sam or we just did a wonderful job.

Thank you very much -

Thank you - Thank you so much - Thank you for everyone and yeah, see you next month maybe and yeah, all the best.

And thank you, Dr. Barry.

Thank you.

Thank you, Dr. Munir Kamas for being against today.

And thank you, Dr. Heba Dremir.

And thank you all.

Thank you so much.

Thank you so much, bye-bye.

Thank you.

Thank you, all right.

We hope you enjoyed this presentation.

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