SUMMARY: Nancy Epstein, MD, Editor of SNI and Spine Expert, discusses another controversy in the management of Spine and Spinal Cord Disease. She reviews the literature on the management of Central Cord Syndrome (CSS). Emergency Surgery in less than 24 hrs since the accident is superior to non-surgical treatment later. She discusses next steps the surgeon must take: Immediate OR, spinal cord monitoring signals; fiberoptic intubation, prone and neutral neck position; midline incision 2 levels above and below lesion; removal of the lamina using a drill laterally, removal of lamina segment by segment. arguments for and against opening the dura, dural grafts, laminoplasty?, intra-operative steroids, post op care; long term results, anterior surgery and more. Lecture and summary is a very complete review of this topic. 20 minute lecture 35 min Questions and Discussion. (JIA)

SUMMARY: In part 2 of this series on the Nutritional and Biochemical status of the operative patient, Dr. Blaylock starts with the operative state of the patient which is entered with the incision. At that time forward the patients metabolic status changes to Hypermetabolic as the metabolism of millions of cells in different organ systems is placed under stress and maximum metabolic demand. The trillions of metabolic reactions, are all demanding nutrients, vitamins, metal ion cofactors, antioxidants, and nutrient energy. Added to these demands are the cells in the immunologic system, adrenals, cardiac, liver, kidneys, respiratory & CNS, all requiring support immediately. Cells throughout the body are subjected to biochemical and electrical signaling in these metabolic reactions. Yet, post operatively most of these patients are given glucose water without nutrients to support this hyper-metabolic state. Free Radicals (unstable molecules) which are the natural result of the body's biochemical reactions now are made at a high rate as a result of these millions of chemical equations which are occurring. Without supplementation of these biochemical needs, the patient's metabolism is adversely affected, and their cellular functions are impaired leading to organ compromise or malfunction. Immunologically compromised patients are unable to be adequately protected. All of this depends upon the preoperative metabolic state of the patient. Thus, the patients are more sensitive to infections than "normal" patients. While the patient may appear normal, the vital signs and chemical markers generally do not tell the story of the hyper-metabolic state. It is obvious surgeons need a more detailed biochemical image of the patient's metabolic state to improve the outcomes of surgery, which we have called the "normal post operative course". Dr. Blaylock cites examples of these changes and how proper nutrition can alter the outcomes. Dr. Blaylock gives us a list of supplements which are essential to the improvement in post operative recovery. (JIA). (40 minutes discussion)

SUMMARY: Dr. Russell Blaylock discusses the metabolic condition of the patient pre-operatively, during the surgery and post-operatively. 50-90 % of the patients before surgery are nutritionally deficient in essential Vitamins, Minerals, and Co-factors as necessary components of the millions of biochemical reactions in the cells of the body to overcome the metabolic challenges of surgery, which is similar to that of a patient with 30% burns. The preoperative patient may be on the edge of metabolic homeostasis but is not prepared to biochemically to withstand the challenge of the surgical trauma. Similarly the immune systems are compromised even pre-operatively in evaluations of pre-operative patients assumed to be normal. The intense metabolic demands of the surgery and in the post-operative state are unable to be met without compromising the large number of biochemical reactions the patient encounters with surgical trauma. These defects compromise the patient's recovery, most often ignored by and unknown to most physicians. The aging patient is further compromised as they are more deficient in the enzymes required to carry out these biochemical reactions and require more supplementation to overcome these metabolic changes. Millions of cells are mobilized during and after surgery creating a huge dietary demand to support the healing responses and metabolic repair processes. Sugar water is insufficient to meet these needs without catabolizing other organ systems in the body leading to post complications. A patient's water soluble vitamins are all gone from the body 24 hours after surgery, making this metabolic crisis worse. Biochemical reactions are constantly producing hyperactive molecules (Free Radicals) which represent a danger to other biochemical reactions. With surgery and metabolic stress many more free radicals are produced and require anti-oxidants which neutralize this hyperactive state. Thus, there is a need in these patients for antioxidants, in addition, pre- and pos-operatively. He ends with a list of recommended vitamins, anti oxidants, and supplements.

Part 1 of this 2 part series reviews the essential nutrients to help off-set these major challenges to the body. Part 2 discusses the metabolic challenges during surgery and after surgery which need to be understood to improve outcomes of surgical patients. (Part 1, 37 minutes with discussion)

Summary: Dr. Juan Bosco Gonzalez Torres from Guatemala describes his experience with a subset of craniopharyngeomas that are intrventricular. He uses an endoscope to reach the lesion through the Foramen of Monro and removes the easily resectable portion the tumor. Some he could remove completely but others were calcified and he left some of those portions. His patients did well. What this shows is another route to the removal or partial removal of these very complex tumors which can be very difficult to remove completely. For me, craniopharyngeoma is a "sucker's tumor", which makes the surgeon think it can be removed and that is when complications occur, as it invades the surrounding tissues. Quality of life vs extent of surgical resection is the challenge for the neurosurgeon. There is a recent paper in the NEngJMed 2023 389:118-126 (DOI:m10.1056/NEJMoa2213329) which describes the molecular, biochemical success in the experimental treatment of papillary craniopharyngeomas that provides hope for the future. (JIA)

Summary: Drs. Verdier and Petre from Argentina describe a case of a young boy with intractable seizures who was diagnosed with Rasmussen's Encephalitis. After detailed studies they performed a hemispherectomy, which they show in videos, with an excellent outcome for the patient. Their group at FLENI in Buenos has a large experience in Epilepsy. This is an excellent addition to the SNI Digital® Series on Epilepsy. Put Epilepsy in SEARCH to find a very complete number of videos from basic to complex on Epilepsy for neurosurgeons everywhere. (JIA)

Summary: Drs Verdier and Petre, present a patient with a posterior mesial temporal occipital AVM supplied by the posterior cerebral vessels. It was not amenable to embolization. Their surgical approach described was with the operated side down occipital approach to the operative site. The AVM was removed and the feeding vessels were occluded with a complete functional recovery of the patient. They suggest that this approach be used in lesions in this area of the brain as retraction of the hemisphere is not necessary as it falls by gravity from the operative site, with limited retraction if needed. A ventricular drain done at surgery can also all for more fallaway of the hemisphere. (JIA)

Summary: Dr. Torres, Head of Neurosurgery in the Bautista Children's Hospital in Managua Nicaragua reports on a young patient with a previous diagnosis of Myositis Ossificans, who developed hydrocephalus, that was complicated to treat. Myositis Ossificans is a rare genetic form of the disease which consists of calcification being deposited in tissues during the healing process. He describes the genetic defect. Dr. Torres' patient developed acute hydrocephalus, had an ETV placed and recovered only to return in 3 months with raised ICP. A VP shunt was placed which failed in 2 days for non absorption of CSF and a new ETV was planned but her ventricle size returned to normal and the procedure was not done. 4 months later the patient returned with Hydrocephalus and a new ETV was done. Only three cases are reported with hydrocephalus in a literature search with little detail. Dr. Torres proposes from this experience that and ETV would be the treatment of choice in these rare cases. The discussion was about the treatment of complicated hydrocephalus. (JIA)

SUMMARY: Six presentations were given with discussion. Subjects included were Why and how to do brainstem tumor biopsies?, Intraventricular endoscopic removal of craniopharyngeoma, A new quantitive measure of hydrocephalus using a pupil sign, Myosisits ossificans and hydrocephalus; Posterior, Mesial, temporal-occipital, AVM removal, Rasmussen's encephalitis: hemispherectomy in the treatment of intractable seizures. (JIA)