SNIDigital Innovations in Learning

SI, Surgical Neurology International, an Internet Journal with Nancy Epstein as its editor-in-chief,

an SI digital, a new, editorially selected, global, multimedia resource featuring neuroscience innovations, operative videos, expert interviews, controversies, all discussed for the next

generation of clinicians revealing the truth with James Osmond as its editor-in-chief.

In association with the Latin American neurosurgeons are happy to present the fifth Latin American international neurosurgery grand rounds,

and this is devoted to how I do it in a new surgery series as an eye digital is running. It's held in the last Sunday of each month.

In addition,

SI and SI digital sponsor, the Sub-Saharan African Neurosurgeons International Grand Rounds meeting on the first Sunday of every month. The topic of this session is going to be Neurosurgery

Challenges. How do I do it? The meeting is organized by Yoham Shoki Velasquez with Estrada Bernard, or a lesser up, and James Ousman as moderators for an international audience.

Dr. Velasquez is a Peruvian neurosurgeon or a searcher specializing in cerebral vascular skull base, interventional neuroradiology, and stereotactic radiocergery. He's a

PhD in the Department of Neurosurgery at Helsinki, Finland. and heads the unit neurosurgery of the regional hospital in Cusco,

and does research on ecology, neurology, and neurosurgery.

Moderator and organizer of the International Grand Rounds, this is Strata Bernard, member of the Duke University faculty and retired, former head of neurosurgery at the University of North Carolina,

neurosurgeon specializing in spine, brain, and pain.

He's in the board of directors of SNI Digital, head of SNI Digital Grand Rounds Programs, which are held as you know in Sub-Saharan Africa and Latin America.

Another moderator discussant is Jorge Lasserick, a meritist professor in the Department of Surgery and Neurosurgery, specializing in pediatric neurosurgery U-Shalei Medical Center.

and the final moderator, James Hausmann, creator and founder, SI, SI Digital, former professor at the University of Minnesota, Michigan, Illinois, and UCL, former head of neurosurgery at

Henry Ford Health Systems at the University of Illinois in Chicago is a futurist, entrepreneur, and healthcare consultant.

The speaker for today's meeting on how I do it, the first in our surgical series, is Alar Kari Kondori, who will talk about cindrelindrical mesh reconstruction in its complex final pathologies.

He's at the hospital on Alaminara in Lima, Peru

He's a neurosurgeon in Lima, Peru specializing in pituitary tumors, aneurysm, spine surgery, endoscopy, and trauma

Peru is located on

the western side of South America. You can see that in the map here. The name is derived from the Quechua, which is an Indian word implying land of abundance, referring to the economic wealth

produced by the rich and highly organized Inca civilization from hundreds of years ago that ruled the region The country has vast mineral, agricultural, and marine resources, and they're basically

the economic foundation of the country in addition to tourism, which is a major element in Peru's economic development. One of the favorite designations is Machu Picchu, which is located in Cusco,

outlined on the map there and is the home of Dr. Valdesquez, and

that's located about 50 miles north

the Acusco where the ruins are, or Machu Picchu is located, and there are other museums located in Peru, in Lima, which is where, located in Lima, which is where Dr. Condoria is from. Their

colleagues and friends, it's a true pleasure to invite you to the fifth session of the Latin American neurosarely grand rounds, which will be take place next this Sunday, today May 31st, this

event is organized in coordination with Surical Neural International, where the academic material is incorporated into a digital edition. On this occasion, we will have the participation of two

distinguished neurosargents, Dr. And Professor LR. Karikondori from Ospital Guillermo Menaririgoyen in Peru,

the topic about cylindrical mesh reconstruction in complex spinal pathologies. And also, we have the presence of the distinguished neuroscience, neurosurgeon Professor Summer Elba Baba. He will

speak about the fatal introteline

microneurosurgical repair of open neural tube defects. Does technique matter? This meeting has been conceived as an open and participatory forum, so everyone is wondering by the two share its own

experience and present its clinical case of interest. For sure, our goal is to foster an environment of academic change that highlight how Latin American neuroscience face and solve the unique

challenge of our realities, promoting a friendly, constructive, and enriching discussion advancement of neurosarity in our region, Latin America. So welcome everybody. And now, Professor

Ehler-Carri, you can start with your presentation.

Thank you so much, Dr. Johan Chokke. It is a great pleasure to present this today about my experience

in my hospital. My experience in the Senior Care Research Contusion in complex spinal pathologies is in our hospital. Our hospital is Almenara hospital is the

picture. And this is in Lima City.

Sorry, I think it's only in the first slide. Okay, we are only in the first slide.

Would you try again, please? Okay. Yeah, now now it is now we see the house for that. Yes. Okay. Yeah. Okay. Yes. Yes. Yes. Yes. Yeah. Thank you. I'm sorry. And the department of the

neuroscience in this public hospital of the security social have three the

service or three three partaments, vascular and tumors, neurotome and spine and neuroradiology. Neurotome and spine is the in in I work

and we are our 13 neuroscience in work in this service.

And we remember that Dr. Roca is the

foundation person. of the neuroscience department of the Almenara Hospital. Otoroka is

a pioneer in

the the that know We. America Latin and Peru in neuroscience stability, alignment, biology, and function,

the principles of the alspine

is the best root, or root, yeah,

root, yeah, is the best, uh-huh.

The good evolution of our patients, this is so important and

last, last year or so. The most important for the results in our patients definitely is the societal balance.

What is the complex spinal pathologies when we spoke about that?

Case of infections or infections or

traumatic lessons, the formities and the tumors of the spinal vertebra.

Any to any studies that the treatment of those two minutes is the use of the mesh, cylindrical mesh with

improve of the pain, pain improve and the formity of the kiphosis with a large place or with a long term, with a

good restoration of

the balance. This is important. Radical deployment followed by rigid stabilization is so important in the process of the osteomyel titanium mesh phase, although for stable reconstruction of the

anterior column.

There is no increase in the rate of the recurrence of the infection related to the

inflation. It's difficult in the decision, but it's important that no increase the recurrence of the use of the mesh

Beneficial influence of the title of the mesh is so important in processes emmato-uniseptic in response deletes.

In this case, in this paper, sorry, use the mesh with autologues

in

sarto, boni tisunos in sarto. Yeah, yeah, cylindrical mesh with the autologous bond graph. Yeah, graph, I'm sorry. And did this good evolution of goods

in this in this special case, the article, original article, demonstrate that the tiny mesh case, a factor that the title, the title, in this case on a factor of L4 with mesh

cylindrical and the factor in the future with this picture And but this structure, no complicate the evolution of the patients

This is a complication, a rare complication, but not

problem in the evolution of the case.

What are the new objectives? We have demonstrated our experience in the complex lesson in the management of the

complex spinal lessons.

We use mesh cylindrical. And demonstrate case of

the youth And bring the recommendations of the

experience.

In the initial experience, in my personal experience, we use the mesh

with

this type,

with a similar form, but we don't have

all

the time for the use of this type of mesh

We have this case in the

spondylolistase L4, L5, with a gap score of 4,

and listasis and spinal stenosis, we

use the mesh profile with the

angulation, the Angulation. for the L5 space.

And the final evolution with a good fusion in the space with the use of the mesh. This is initial experience in the use of the mesh

This is low cost because the mesh, I'm sorry, the peak case is the

big cost. Very expensive cost, very expensive, yeah. So you mean that instead of the peak and of the inner body discs, you are using the mesh, right? Yeah, because it becomes less expensive,

but the

results are quite similar. Okay. Okay. Good results.

The first case, Meng

of the 48

years old, and Trump's accident from, he have a Here, Baresis, and the

Luxo, Luxosium, Luxo Fracture in the 6th, T6, and

the 7th, it's a complex and spinal lesion. We denoted the

recommendations and then start reducing the

injury. We have having a low traction is full.

and install no reduce. This is a

compression anterior, no no reduce. We have 50 for a five,

50, 40 grades and salary and posterior anterior, posterior anterior and finally, we have a good reduction, in this case, with the use of the mesh. This is the last resort with a good

stabilization and alignment. But neurology,

because the neurology

is a, No patient, no, half a good evolution, the neurology is complicated.

And the next case, I think somebody wanted to say something, I didn't hear it very well. Did you try to? Yes. I think the microphone of some of the And the

third and the third is with the open microphone.

Okay, and the next case is the main of the 70 years old, this problem in our country, we have five days of the

informal initial initial of the

trauma and he down of the six

of the high. She has a paprika and

pain in the lumbar pain. Oh, Becky. And this is the pictures of the factor A4

of the L3, the A4 type We have a

retroperitoneal approach with

a mesh in this reconstruction

of the body vector black.

And then we posted our fixation with a

pecutan - no, yeah, pecutanios, pecutanios, pedicle, screw it.

And the important in this case is the

approach of the anterior approach by retropetonia, without

the lesion of the

radicularyl Do you do that

to me? Do you do that yourself or do the vascular orthopedic surgeons help? It's an important question because we only, only in

the surgery, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, you don't ask an abdominal surgery or vascular surgeon

for that case, but you are operating by yourself. Yeah. Okay. How many neurosarians operate? In this case, how many neuroscience were in

this case? It's frequently two neuroscience and one resident or assistant.

Okay.

In other case, this is a woman of with 56

years old We'd fill out this two more in mastectomy in 2025. The he she has a package and purpose and this is the pictures of the lessons with a compromise of the

Spine Canal with

compromise, neurology compromise. We have in the similar approach, retroperitoneal approach. In this case, amp, and corpectomy, and xerases of the lessons posterior with a fixed axion, three

levels superior and inferior. With a

good result, we've got stability, and it's similar. We have all surgeries, only neurosargium apply in the surgeries In

this, in the approach, no need a. for approach, no need the other,

sorry, other case. Sorry. It's a, sorry.

Do you do a 360 approach you operate from the side and take the

broken vertebral body pieces out? And then you come from behind and you do the fusion? Is that what you do?

I guess nobody's, Jorge, could you translate what I just said? Yes, the

question again, repeat the

question. He operates as he operate from the lateral paraspinal approach to remove the bone and to put the graft in and then he operates from behind and does a fusion, is that how he does this? No,

that's why I got it, but not being able to do it.

I was able to do it in the part of the lateral paraspinal approach to the

lateral paraspinal approach to the

lateral paraspinal. Yeah,

I in two steps now, but the first is lateral position and the last is the ventral the ventral, the

COVID, you know, the other position, finally.

And all of these people are there, they're paraplegic or they have a fixed deficit as that's all, that's, from what he says, it's not what I assume is happening right before, can you ask him that?

Yes, so the question is that all the patients do have paraplegia or fits deficit before, right?

Yeah, they don't have a fixed deficit,

it's a, they recover after surgery.

So, if they don't have a fixed emphasis, they can recover after surgery, right? Yes. And in all these cases, what I understood from before also, is that none of them had fixed cases and all of

them or majority of them recovered after surgery, all

of them. And is the surgery

done acutely? Thank you very much.

but it was stronger usually it's a delay of five days and in the case of the of the tumor the delay can can be as long as 15 days and all the equipment okay

okay very challenging cases well it's only the gasoline

challenging come on the PC a

deficiency perositum desafientes so in

case a continued and is a woman of the 65 years old and she and

have a salary previously

for for fracking.

lumbar L1. She has rheumatoid arteries. In the first surgery, this is ark or metallarck The

evolution of this case is

with more key forces and instability with compromised neurological compromised.

This case is an article that I

mentioned of the predictors of the bat evolution

This patient has rheumatoid arteries and chronic

chronic disease,

paralysis, compromise of the bowel and bladder dysfunction.

In this case, we have in

the surgery with a approach, with retropic tunnel approach, it's the similar.

But the mesh is the oblique. But finally, it's a good fusion with a good recovery of the

neurological deficit.

This case, we have osteoporosis And we,

our mentorship, we are not going to do that.

with the cement.

So for these for these cases of osteoporosis, are you not experiencing any subsidence issues?

subsidence?

No. In this case, no. But in other cases, yeah, is so frequently. But we have a good perfection in three levels.

The stability is good

with more levels of fixation now.

So, in general, what

criteria do you use to avoid the complication of subsidence, especially people who are as imporotic, because that will be a concern with the stiffness of these cages? What

subsidence? I don't know. Yeah, what is subsidence?

So if subsidence is the collapse of the vertebra adjacent to where you have the. Indicate. Your

aligraph,

and the way you have your cage.

So where you might have fistening in where we just protrude into the adjacent vertebra

So what happens in the adjacent vertebra?

And you have the cage, and then the adjacent vertebrae to the cage develops a collapse also. You call that subsidence? Is that true? Yeah, it pushes into it, yes. Because it's - Oh, it pushes

stiff. Yes. Oh, is it enough to do anything to do with osteoporosis or no? Well, more at risk in cases of osteoporosis, again, because

the cage is much more robust, much more stiff than the native bone. And then you're like, What's the problem? No, no. See, basically, there's a subside, and then there's a collapse, and

there's a particular area there. See, it's difficult to get in a coconut. If you have osteoporosis, you're going to have osteoporosis, and then you're going to have osteoporosis,

and then you're going to have osteoporosis.

the vicittarius. May you say it's a problem and pass in the connoisseur process?

Okay, you translate what you just asked him?

I explained or I repeated that the subsidence was the naturality at the collapse of the vertebrae on top of the mesh, more prone to it to happen in patients with osteoporosis because of the frailty

of the vertebrae and whether he sees those things in the his patient, you know

And

this is

the necessary component of the competition.

What he says that he is, that they do have some silence and for the other reason they made it a longer mesh and they added cement to higher vertebra to stabilize, so I say those vertebra body on top

of the mesh. I see, okay So they

put the cement, where does the cement go? In the mesh and already their end and so forth. And into the vertebra above and below, they'll put a piece through the. So it has something to anchor

onto is

what you're saying, right? Well, it gives it more, it makes it more robust so you'll be less likely to have that sinking in effect.

So I guess because if in the cases of osteoporosis, you have a

more rigid construct with your cage and that would just collapse, that would make the adjacent vertebra collapse. But if you can give them more structure, make them more robust by adding cement to

the adjacent vertebra, then he's saying that reduces the risk of you getting their progressive sinking effect. No. No.

I don't know. Yeah, Jim, these white images, I don't know, will be on the right, on the bottom. Those images on top of the mesh, on top and below, those white spots, is the cement that they

put in. Yes, okay, babe. Is that cement also for where the screws are?

In the fusion?

I mean, it looks like it's right where the fusion would be, right? Am I right or strata or wrong? Well, this cement gets placed through the pedicle.

Okay, okay. And then you can, so you go down into the pedicle inject the cement, but then you can, through the same pedicle you can put in pedicle screws. Put in the screws. But is that what

you did? Yes. Yes, that's what it

is, yeah. Yeah. I mean, these are, it's an oral control of the patient. Yeah, these are amazing cases. Yeah.

So, even with the fusion, even with the fusion, and the screws and so forth, you would get that because of all the forces. You can still get

the telescoping into the adjacent vertebrae, is that right? But that minimizes it, am I right about

that? That is

right. Good. And he has people recovering neurologically after this? Yeah. What does

he do about a Dural leak and repair? I don't know if I'm asking the right questions, just try to, but this is a very complicated problem

How does he deal with repairing the Dura and all if it's sworn and so forth in a CSF

fleet? I'm not sure.

I'm not sure. I'm not sure. I'm not sure. I'm not sure. I'm not sure.

I think that's a significant thing. You know, in a laboratory, you know, you're a component of a component. Hey, I'm a collage, you know.

Yeah, usually he has a CSA fistula in the anterior portion of the approach. And they block it with collagen. They stop it with collagen.

And that's a fact of it, it seals it, is that right? Much, much, yes, if it was, no, she'll do not need a problem. But no, no, no, yeah.

So far, they have real troubles secondary to the fistula. So apparently in the, apparently in the anterior, apparently when he performs the, these cases, he usually performs the anterior

approach. And the cases of CSF leak became in this approach So he's saying that. In that case, usually you don't need to repair, just you tamponate a bit with collagen, and

the results are quite good. But if the approach is posteriorly, then he needs to shoot you the endura and put some graft.

These are very complicated cases to be, I don't know, Strata, what do you think?

I don't know, but I think they are indeed, and he's doing a good job dealing with them. Yeah, I mean, how many cases do you have like this?

How many cases do you have like this?

Approximately in our spinal service, we have 20

cases in one year. Wow.

And these people,

what's the infection rate?

Yeah, infection is the most frequently.

What's the percentage? Is it 10, 15, 20? Is the 60 approximately of all the

cases in need mesh? No, but of the infection is a different question The question is, what is the most important thing in the world?

Yeah, from the clean surgery, none. They have patients who come already infected and they may need a re-operation. That's what I didn't understand with. Wow, it's very complicated.

All in case. The woman of the

77 years old, she has urinary infections frequently and

this is a mice of the MRI, the compromise of the L-free disc and the distribution of the body or vertebral body of the R4. In this case, in the similar approach, in

only case, they use a mesh of the

expanding. What percentage of cases does he use a mesh and what are the indications for the cage?

It is the only one.

Is it similar, Mitch? Mitch? It's similar, Mitch. It's

only

the empressa.

Does he use the mesh, the cage, or the mesh in all of the fractures, or just some of them? I mean, what are the indications for the mesh? Mesh What is the indication of the mesh in the mesh?

The only indication is the

empressa corporeal, no? The body replacement, no? Yeah, body replacement and the reconstruction of the perfield or the sagittal balance.

And keep the balance on reconstruction of surgical balance, I don't know if I've made sense.

So if the bone is all broken up and so forth, he has to take it all out, then he puts a cage in. Am I right about that, I just try to, I'm just a vascular surgeon, I'm ignorant about this.

Right, so the question is, anytime he does an anterior column reconstruction, does he use a mesh or does he have other alternatives?

Well, he says he doesn't use peak because it's expensive and he's saying this is the advantage of using this, but

he's not using autologous bone, although he's filling the cages with autologous bone. Right. I

believe,

but if you could answer that, You know, if you could answer that. So anytime you need to do an anterior reconstruction, Dr. Osman is asking,

do you always use the cage, the

cylinder, the mesh? Anytime you do an anterior spinal reconstruction in the thoracolumbar spine. Correct.

Okay. Yeah, okay.

Okay, there's your answer, Jim Yeah, that's,

these are really complicated cases, wow.

These are complicated cases. of the woman of the 77 years old. She has

only deformity, progressive deformity of the k-forces, lumbar, lumbar k-forces And the process so infectious in

the L2 disc and a collapse of the body vertebral of the L2 and L

partially

L1. But I compromise of the

psoas muscle in the bilateral and you know, coronal instability, too. Did she have any neurologic deficit?

She has. no deficit. Yeah, only Q forces and pain. And 77 years old, amazing. Yeah. And she came to the surgery fine.

She did

well postoperatively. Sorry, it's a salutavian della cirohere to definitely. Yeah, this case, this is the approach with a good second option on the vertebral co-pectomy at two co-pectomies. And

good alignment, it is a control of the six months,

six months posterior of the surgery Where he is incorporated is

non-neurological good recovery. In this case, the

postoperative course, no, no, no infections, no complications or minimal complications. Or is that, is that right? I mean, yeah, the infection statement, we call the

MRI, demonstrate the persistence of the SOAS collection with this. But in the last control, it's a good recovery with

an imagine and a clinical, clinical and imagine recovery good. And what was the organism? I think I missed it. Was this a bacterial infection?

What kind of reflection was it? It looks like she had this Paris finest infection in the sewers is what he said. Is that right?

Okay, okay, but they are a lot of it's young. Don't know. Yeah, it's

the castle. See it on the stuff It

was

cured by antibiotics, right? It was cured by antibiotics, right?

Antibiotic is the perengula, the basic. The what? The antibiotic is the

perengula Antibiotic is the philosopher's tone of the treatment Okay.

Does he how many older patients does he have that's a an excellent result? Yeah Are

you gonna tell us who cares? Yeah, you know, I know we're as or they are going to go door with the zero one focus or on it is uh-huh in in our Service never term on spine in hospital and menara al

menara hospital We have 20 cases per year and about the use of the mesh Know how complicated Direct with a dispositive mesh With our good balanced sagittal and stability or segmental stability The

mesh

cost is approximately one 1, 700, 1,

700, no. And we use more

mass basis, more for more patients, two or three patients.

We, in this is the, other cases, three cases, we have the mesh, only mesh without,

without bone graft,

especially in infections, patients, or

with a good result, with fusion So he doesn't use a bone. the bone graft at the same time, and he gets no infections. Is that right? Yeah. In cases of infection, he doesn't use - In actual

activities. Yeah. No, okay. Okay. Terrific. It's

especially important, considering the cement with augmentation, with the

cement, it's an infectious process. It's no - it's difficult

and not necessary, because it's

with a obtained infection of the currents

Actually, we don't use

infections, active infections. no use cement with a limitation in our science. Because you're concerned for infection with infection now. Conclusion, the

cost and benefits is a good, the use of the mesh,

the approach is important In all case, it's

less difficult to put the mesh in for a lateral anterior approach, retroperitonia.

This is important because a good societal balance and stability is fine I

try to hear Mark's experience by far than I am in this. How would you look at this series of cases? What's your thoughts about it?

I think, well, first, thank you, I think he's got, he has a

good experience going, I'm

intrigued that he's not having any subsidence, so I guess what he's doing is working because it's one of the concerns with these cases using cages, especially people with osteoporosis that tends to

happen, but it looks like he's doing a good job reestablishing sagittal balance and I think that's probably a factor in his outcomes He's also got people, he operates on with a deficit to improve,

right? Yeah, well, and the other thing is, at least in the

United States, most neurosurgeons don't do the approach for the for these anterior cases and tend to work with an approach surgeon, usually a vascular surgeon, a general surgeon, sometimes

urologist, but Dr. Carey is doing the whole thing all by himself. And actually, I'd be curious to ask you, Ela, how did that evolve because our experience in the United States is usually

neurosurgeons use approach surgeons, so how did you evolve to doing the whole thing all by yourself? Did you initially use approach surgeons and evolve from that, or did you start

with doing the whole thing without an approach surgeon?

And you can stop sharing your screen now, Ela Hori, or you owe him, you want to translate what Estrada's question was?

Lumbar is the first one, L5 is not.

Yeah, he did one, two, he did a few cases to the elite And then he decided to go alone. And he may call them if while he's working on the process, there is a complication or a difficulty.

Okay, well, very good. Well, I'm interested in the participants if other neurosurgeons in Latin America do the same. Is that typical for that part of the world that they generally don't use a.

I'm just curious for those who are participating in this session if they have similar experiences. Anybody can speak up I think that the first thing that I think is interesting is that the first

thing that I think is going to be a part of the issue

is that the people who are participating in this session are coming from the public I don't think it's going to be a part of the issue. I don't think it's going to be a part of the issue. I think

that the issue is going to be a part of the issue.

I think the most important

thing is

that the people in the city are not going to be able to go to the city I don't think it's going to happen. I don't think it's going to happen. He mostly says, obviously, he says that

mostly they do

that thing as he does, but based also on an economical reason, because that the patent for the approved surgeons, so we call it that, it's extremely low.

It doesn't compensate, it's not an incentive

Strata if this if he was doing this in the United States and he presented this series of patients. How would this be received?

I mean, to me, I'm not a very knowledgeable person here, but he's tackled some very complicated cases. He's done it very well. Yeah, well, I think, I mean, I think, spine surgeons in the US

have similar experiences. And, you know, there's some people that have real high volumes. But, yeah, I think, I think it'll be well I mean, I think I keep our harping on the approach certain

issue because I think usually that's not the experience in the US.

But certain in the US who do complex spine surgery, when they do this sort of thing all the time as well. Okay.

I think you just done an excellent job

Thank you so much for your audience.

Well, any questions from the audience? Any questions or comments? Thank you, Jorge, for helping with moderation and Ilhar, thank you very much for presenting your cases and very impressed with

your outcomes. So with that, we'll close and we will resume in a month with the final Sunday of the month. head center. Thank you very much. Thank you very much.

Bye. Bye bye. We hope you enjoyed this presentation.

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Cylindrical mesh reconstruction in complex spinal pathologies; Latin American Grand Rounds; Elar Cari Condori, MD; How I do it.

Elar Cari Condori, MD

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