SUMMARY:  The Most Common Cause of Spine Malpractice Lawsuits is the failure to Diagnose and Treat emergently Partial or Complete Cauda Equina Syndrome. The diagnosis must be made early and  Surgery must be done ASAP after that diagnosis is made.  Dr. Epstein provides a review of all the evidence supporting this decision.  Excellent Graphics and Teaching. Good for Video and Podcast.  (35 minutes)

SUMMARY: This is the complete Lecture and Discussion series of this three part series which takes 1 1/2 hours of viewing.  Dr. Epstein Covers the anatomy, pathology, imaging, and clinical presentations of Cervical Spine pathology. She then provides the keys to selecting the correct surgical approach to lesions in the C-Spine axis. She describes the use of the K line in making that determination with supporting data for all her statements and in the references at the end. Multiple case presentations with malpractice case experience. Excellent series for Young neurosurgeons, and staff and also as a refresher for experienced neurosurgeons with an update on the literature. Lecture and discussions 1.5 hrs. (JIA) 

SUMMARY: Drs. Nancy Epstein and Estrada Bernard, two experienced spine surgeons discuss the management of Thoracic Discs. The major lesson is do not do a laminectomy. Then they discuss the various anterior and lateral approaches to the thoracic disc with surgical tips for the spine surgeon. How to deal with the large central disc? What to do in situations you have trouble with? Trans-pedicular, costo-transversectomy, extra-cavitory or, or trans-thoracic approach? Pros and Cons of each. From Latin American Neurosurgery Grand Rounds. Excellent graphics and Discussion. Good for Video and Podcast. 75 minutes of good discussion.

SUMMARY:  Dr. Russell Blaylock, interviewed by Dr. Ausman, describes the new direction the understanding of the causes of Cancer are taking. In the past, we believed that Cancer was a genetic disease, and  so, the genetic composition of many cancers has been studied extensively. What was found was that there were wide variations in genetic abnormalities of cancers while one would expect that there might be similarities in the genetic pattern that would explain how cells became cancerous. Dr. Thomas Seyfried performed an experiment in which a tumor cell nucleus was transferred to a cell with a normal cytoplasm, believing that the genetic changes in the nucleus would be expressed in the cell as it grew to become a cancer cell. But, the cell continued to be a normal cell. Yet, when a normal cell nucleus was transplanted into a tumor cell cytoplasm, a tumor grew. This experiment indicated that for a cancer to grow, molecular contents of the cytoplasm of the cell were necessary to support a cancer growth.

Over time it was discovered that many different agents caused cancers. What was common to all of these agents was an immunologic- inflammatory-excitatory cascade in the cell cytoplasm to toxic agents which initiated these cancer changes by causing disruptions in the metabolism of the cell and mitochondrial energy sources. Actually as Dr. Otto Warburg found in 1931, cancer cells find alternate ways of growing by taking over the cell metabolism from the usual cytoplasmic glycolytic and mitochondrial tri-carboxylic acid cycles and using alternate routes of metabolism forming pyruvate to lactic acid.  Along the way  the new tumor cell metabolism blocks all the normal cell protective systems that keep it a normal cell and allow the tumor cell to grow into a large tumor. Some of the agents initiating these toxic inflammatory changes in the cell are smoking, some vaccinations, all kinds of toxins, alcohol consumption, toxic metals, microwave radiation from cell phones, anticancer drugs, radiation, and Covid 19 vaccine.  

 Cancer cells thrive on glutamine which is common in our high sugar diets. Glutamine is converted to glutamate in the body which stimulates the growth and invasion of the cancers. The cells effected are the small population of Stem Cells, or multi potential basic cells, which are everywhere in the body that grow into these cancer cells and produce more cancer cells. Dr. Blaylock explains in more detail in this and a second video what happens to convert a normal cell to a cancer cell and how to prevent that change with naturally occurring agents.  Chemotherapeutic agents and Radiation treatments used to prevent cancer can accelerate it as they initiate cell damage and then the immuno-excito-toxic pathway leading to disrupted cell metabolism and initiating cancer growth. This will change your perspective on cancer.    (JIA)

SUMMARY: Dr. Giuliana Agras Menghi presents a rare complicated case of CLOVE syndrome. Listen to the clinical story. What would you do for this patient? She does not have a terminal disease. The family of 5 children has no insurance. What is your choice? From Latin American Grand Rounds. 48 Minutes; Good for video.

This video presents a pure endoscopic approach to the pineal cyst in prone position with head extension ( the so called anticoncorde position) and some head rotation. The head is in gentle extension and rotated 30 degrees to the right shoulder and a surgeon sits at the patient's left shoulder, looking into the patient's occiput. 

Pineal cyst are often present on brain MRI imaging, but are rarely symptomatic and rarely there are indications for surgery. Size is important parameter in pineal cysts! Small cysts <10 mm in diameter, surrounded with CSF layer, certainly can not have any compressive effect. There are also cysts larger than 10 mm and asymptomatic.  

These are hard neurological signs which represent absolute criteria for surgery: hydrocephalus or asymmetrical ventriculomegaly with signs of compression of lamina tecti and aqueduct stenosis, dorsal midbrain symptoms, diplopia, Parinaud syndrome, positional headache with foggy vision, papilloedema..….Also benign cyst may rarely bleed inside and become compressive (symptoms may resolve with blood absorption).

Some radiological signs may rise suspicion of tumor rather that benign cyst: irregular thick or nodular wall, solid components, irregular enhancement, diffusion restriction, invasion/edema to LQ, progress in size….  

Headache alone is not indication, also if accompanied with some soft signs, but not linked to hard signs, such as: intermittent ill defined subjective vision & sleep problems, dizziness, fatigue, cognitive symptoms, attention problems, study problems,.…………………..although symptoms improvement may follow the surgery in more than 90 % of such soft-signs-cases & > 10 mm diameter, but have 23% complication rate.

Selective patients with severe, refractory symptoms and cyst at least > 10 mm, with decrease quality of life may have benefit from surgery (evidence emerging). Young women between 20-30 are mostly affected. Some young patients may be very persistent and insist on surgery, despite the neurosurgeon can't find firm indication; the presence of cyst is considered by some patients as source of their problems, as something is wrong in the head (should not be there) and thus see a pineal cyst removal as a solution of their problems. The trust between patient and neurosurgeon can easily be lost. Very rarely, pineal cysts were reported to contribute to sleep disturbances, which in turn can worsen or trigger psychiatric symptoms.

Asymtomatic cysts are observed, MRI repeated at 12 months, if there is something suspicious, repeat MRI first at 3-6 mo, then at 6 mo and if stable at 12 mo, later stop follow up).  

SURGICAL APPROACHES    

Microsurgical approaches enable complete or near complete cyst removal, good controlled exposure of pineal veins, qudrigeminal cistern and tectal plate, in some positions (sitting, semisitting) gravitiy effect helps to self-expansion of the corridor– but danger of air pulmonary embolism. 

1 paramedian supracerebellar infratentorial corridor (sitting, semissiting, prone concorde)

2 occipital transtentorial (park bench, semiprone)

Endoscopic transventricular approach – ETV (if hydrocephalus or obstruction to CSF flow), sometimes - in larger cyst protruding into 3rd ventricle - enables also biopsy and fenestration of the cyst (flexible endoscope can be used alone or in combination with shaft of the rigid endoscope). This surgery bear risk of fornix injury and are problematic with normal, narrow ventricles (despite navigation device caudate and thalamus can be contuded). 

Purely endoscopic supracerebellar- infratentorial approach (eSCIT) enable an access performed through a paramedian suboccipital keyhole (subtorcular) craniotomy, with an assistant holding the endoscope while the surgeon performs bimanual microdissection. Endoscopic surgery can be done in prone, sitting / semisitting / park‑bench /semiprone positions. There are two variants of prone position:

prone – concorde (head in flexion, surgeon sits behind the head and works in reversed anatomy)

prone – anticoncorde (prone with head extension and right-sided rotation; surgeon sits lateral at patient's left shoulder)

Advantages of anticoncorde head position: gravity‑assisted cerebellar relaxation similar to the sitting position, improved venous drainage, reduced risk of venous air embolism compared with sitting/semi‑sitting approaches, panoramic view, safer bimanual dissection through pineal veins, complete microsurgical removal possible.    

 SUGGESTED READING

Spazzapan P, Velnar T, Bosnjak R. Endoscopic supracerebellar infratentorial approach to pineal and posterior third ventricle lesions in prone position with head extension: a technical note. Neurol Res. 2020 Dec;42(12):1070-1073. doi: 10.1080/01616412.2020.1805926. Epub 2020 Sep 5. PMID: 32892737.

Hua W, Xu H, Zhang X, Yu G, Wang X, Zhang J, Pan Z, Zhu W. Pure endoscopic resection of pineal region tumors through supracerebellar infratentorial approach with 'head-up' park-bench position. Neurol Res. 2023 Apr;45(4):354-362. doi: 10.1080/01616412.2022.2146266. Epub 2022 Dec 12. PMID: 36509700.

Uschold T, Abla AA, Fusco D, Bristol RE, Nakaji P. Supracerebellar infratentorial endoscopically controlled resection of pineal lesions: case series and operative technique. J Neurosurg Pediatr. 2011 Dec;8(6):554-64. doi: 10.3171/2011.8.PEDS1157. PMID: 22132912.