0:01
SNI Digital, Innovations in Learning, a 3D Live video journal which is interactive with discussion and now it's offering podcasts on Amazon and Spotify soon to be on Apple under the heading of SNI
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Digital.
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In association with SNI Surgical Neurology International, a 2D internet journal is pleased to present Sam or El Baba MD, who is the chief of pediatric neurosurgery and the president of the Leon
0:38
Pediatric Neuroscience Center of Excellence at Orlando Health, Arnold Palmer Hospital for Children, and the professor of neurosurgery at the University of Central Florida College of Medicine in
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Orlando, Florida.
0:56
Dr. El Baba will give us another talk on endoscopic assisted neurosurgery. Endoscopic control versus endoscopic assisted microsurgical approaches for pineal region tumors in children, an
1:13
interactive discussion of approaches. The discussion will be James Owlesman, yes sir. This is another opportunity we have talking with Samuel Baba, he's Chief of Pediatric Surgery and Director of
1:30
the Leon Pediatric Neuroscience Center of Excellence at the Arnold Palmer Hospital for Children in Orlando, Florida, still a professor of neurosurgery at the College of Medicine in Orlando. And we
1:43
just talked about fetal surgery in which he's one of the few people in the world that is doing this And this talking's gonna address the issue of pineal tumors.
1:57
and using endoscopic control versus endoscopic assisted micro-surgical approaches. So we have a high interest in endoscopic surgery. We think that's gonna be a major part of neurosurgery in the
2:13
future. I think you know Roman Boschnak and Slovenia, who is a world leader in endoscopic surgery. So why don't you go ahead and tell us about your work in this area? This is Osman, it's a great
2:26
honor and privilege to be back with you. And thank you for having me again. The scope of this talk would be focused on using different techniques for treating pineal region tumors primarily in
2:38
children who talk about a combination of microsurgery, endoscopy, and endoscopy assisted surgery. As we all know, whenever we deal with deeply seated lesions in the brain or in the ventricles, we
2:50
need to always think about the anatomical corridors.
2:55
using, like let's say when we use endoscopic surgery for the ventricle, we have to think about the gray matter we're going through. We need to think about the white matter tract we might be
3:05
disruptive in the way. And we need to always think about the surrounding structures. We always talk about
3:13
the ideal entry points based on eloquent parts of the brain. We always talk about speech areas, motor areas We talk about highly inequent white matter tracts like corticospinophthalamocortical or
3:28
optic radiations. But the truth is that the whole brain is eloquent. And this was always reminded, I was reminded by my mentor, Professor Yashhagod during surgery, always that the whole brain is
3:40
eloquent. Whatever we do, we should always think not only about what we're doing, but how we get there Professor Pinetsky was a leader in the field of was a leader in the field of.
3:54
Indiscopus is a micronary surgery. He described it as a minimally viscous technique with maximum effective treatment. Let's take a pause here, especially for the trainees watching us today and make
4:07
sure that we have an excellent understanding of different terminologies. Indiscopic is when we use the Indiscope for both visualization as well as the work we do, like when we do ETV surgery. We're
4:21
using the working channel of the Indiscope to replace the device, and we do the visualization. Indiscope control is when the instrument is used parallel to the Indiscope, similar to transformodal
4:33
surgery or Indiscope assisted. This is when the operation is actually performed with the microscope that you bring in the Indiscope in certain parts of the surgery to assist with
4:49
visualizing areas the microscope is unable to show us is unable to show us. The technology of endoscopy continues to advance. Now we're going from zero to 30 to 45 and in some endoscopes up to 70
5:01
degrees. There's nothing wrong with going back and forth between microsurgery and endoscopy. Like in this case, I'm doing a semi-sitting position in a pioneer region tumor. I go back and forth
5:14
between sitting and my arms up and using the microscope into take a break, bring the endoscope and looking into some parts of the surgeon with the endoscope. Can you go back to
5:26
that slide for me? Yes, sir. If you look at the left hand of that slide, what position is the surgeon in? That's probably one of the most uncomfortable positions you can be in. Absolutely, and
5:39
your arms are extended, you're working uphill, you get fatigue, we'll come back to that at the end. Okay. Absolutely, and frankly, when you go back and forth with endoscopy and microsurgeons
5:51
selected. cases, it makes a difference also for the surgeon itself and expedites the operation. The pineal region is very unique specifically in children and the pathology of those tumors dictates
6:07
what we should do for them. But we should always remember that over 50 of tumors in the pineal region are germ cell tumors and most of them or many of them are treated with adjuvant therapy. So
6:21
tissue diagnosis is very essential. The three classic open or microsurgical approaches to the pineal region are the
6:32
supracibular infra-tentorial, supracibular suboxypetal via trans-tenteral approach or the PCR trans-colosal. Selecting the approach to do supracibular infra-tentorial depends on the
6:44
pathology, the size of the tumor and the experience of the surgeon even when you go super set dollar. Do we go midline or we go peremedian? Again, it all depends on the comfort level of the
6:55
surgeon. Understanding the anatomical landmarks is key. Identifying the anatomy of the inion and planning the craniotomy. In some cases, some people will take the craniotomy above the torskula.
7:11
In my practice, I just go infra tintorial. Understanding the venous anatomy is essential for performing those surgeries successfully. Obviously, understanding the anatomy and location of the
7:23
torculine transverse sinuses is important. And there are some veins that are superficial, like the inferior vermin veins that are safe to sacrifice. But once you get deeper in the supras cerebellar
7:36
approach, we get into important venous structures like pre-centra cerebellar vein and others and those veins cannot be sacrificed and they're essential Selecting the approach also can be dependent.
7:49
on the anatomy, like in this case the angle of the tintari, which can be different from different patients. And the tintari angle has been studied by many groups, including Professor Turin, his
8:02
group in Istanbul. I found actually studying the tintari angle can be essential in deciding the approach for certain cases, like in the Meso-temporal lobe resections. The younger the children, the
8:16
more difficult to do penning, if we do, like let's say, a semi-sitting position. So we are able
8:26
to do the semi-sitting position in young children down to the age of two years without penning. And nowadays, we have different head holders that get lost to do this work without using pens. We
8:41
have a protocol in our program for doing
8:46
the semi-sitting position. We start by a CT to evaluate the skull thickness, where we do the pens, we do the echocardiogram to look for any hard defects, central line, do interactive TEE, and we,
9:02
if the patient has a PFO on the echo, associated with shunting through the PFO, then we cancel the plan for a semi-cerein position. Going back to the pathology, over 50 are germ cell So doing
9:20
combined ETV for treating the
9:28
hydrocephalus, in the scope of the ventricle mastery, and pineal bopsie is important, especially in children. Like in this seven month old baby, a severe hydrocephalus, and large pineal region
9:33
tumor, after the ETV was done successfully, now going through an interior hairline entry point. Now I'm looking from anteriorly to posteriorly, this is the mass of intermediate. This is the cora
9:48
plexus in the root third ventricle doing biopsy of the mass. And the mass came back pineal, that's pineal blastoma, and we intersected it completely through the super cerebellar approach. This is
10:01
a similar case, been an older child, 15 year old with pineal region tumors symptomatic either selfless. We did the same thing. ETV and pineal biopsy came back to her minoma, melted away with
10:15
adjuvant therapy, chemo plus minus radiation. So you can see here two children treated differently. So the biopsy is very essential. This 16 year old boy presented to us few months ago with upward
10:29
gaze palsy with headaches. You can see this pineal mass. We started, I always plan to do two entry points to avoid too much manipulation of the forensics, but it depends on the case. In some
10:46
cases, we're able to do both through one point. So we start with one and extend the insertion to do a second one if needed. Like in this case, the ETV has been done successfully. And after the
11:00
ETV is done, through the same bare hole,
11:05
I am looking at the tumor after the ETV was completed. And now I feel, so with this 16 year old bowl, severe headaches and upward gaze palsy, we did normal pineal region tumors, tumor markers
11:20
like AFP and beta-XCG. After the ETV is done, we do take a look at the tumor. In this case, we're looking at it, able to get a good biopsy. After the biopsy is done, this came back as germinoma,
11:38
adjuvant therapy was done for eight weeks and you can see the tumor melted away and the scope control. Like in this case, 14-year-old girl with increasing size of cystic mass in the pioneer region,
11:52
simsitting position. And in this case, no microscope was used. Gravity assisted supercellular approach that's completely in the scope control. After sacrificing safely the small midline inferior
12:09
virulent veins, they're so safe. Now we extend the endoscope into the supercellular space and you can see here Tintorium, Tintorium, midline, the vein of gallant, right thalamus, left thalamus.
12:17
And here you can see
12:23
now you see
12:26
the paddy here over the cerebellum. And you can see here the right basal vein and left basal vein and the mass is here. Let's take a look at a better look here. Now we're doing a section to
12:40
separate the mass from the right basal vein of rosontal of the universe in Dell, and circumferentially dissecting the mass. Again, all done in the scope control. Now, we are going
12:52
circumferentially. We're careful about the intersabral veins in the roof of the third ventricle, and then we do bimanual. Now, the assistant is holding the endoscope. Now, dissecting the mass
13:04
from the right thalamus, and go circumferentially
13:10
And after that's completed, taking the mass in one block after circumferentially, dissecting it from any attachments. And after the mass was removed, we explore with the endoscope again, and all
13:25
the venous anatomy is preserved. You can see coral plexus in the roof third ventricle, right thalamus, left thalamus. And here you can see no edema in the cerebellum, very small craniotomy and
13:36
venous anatomy is all preserved. In a semi-sitting surgery,
13:45
or a citizen in position, the importance of positioning is critical. How about endoscope assisted microsurgery? You can see here, like in seven-year-old child with temporal lobe seizures,
14:02
you can see there are different approaches for
14:07
this mass, and this can be done via trans-cortical, or via anterior temporal classic epilepsy surgery approach, or supercellular trans-centorial. In this case, the child who had medically
14:23
intractable seizures, this is the dominant temporal lobe in this child with normal neuropsychological testing. We felt it is
14:33
not safe to do
14:36
trans-cortical injury to the temporal lobe And when we looked carefully at the flare and T2. signals here or intensity, you can see there's edema around the lesion and the peri-hypicampulgeirus in
14:50
this case. Can you see it here? Yes, okay. So, this approach, doing supercellular transcentorial to the mesial temporal lobe, was described by pioneers in the field like, late professor
15:06
Delavera, also Professor Yashigula, Professor Turre, and Istanbul.
15:18
And this approach actually trans-central allows you access to the whole
15:24
mesial temporal lobe.
15:29
Here you can see we do a pair median incision.
15:38
And we'll start with the uncomfortable microsurgical approach. Here you can see, open the dura over the left cerebellum, opening a sharp place to start a magnet to release CSF. And now the
15:54
cerebellum is relaxed Now we'll bring the endoscope
16:03
And now, via the endoscope, we use the
16:08
transcendental opening carefully by protecting the fourth nerve. Then we do a excision of the mass via the transcendental opening using the aspirator
16:27
Here you can see it's a classified mask.
16:36
And now we put the Indoscope back
16:41
and now we find out actually that we left the residual lateral to the PCA and this residual now we're going to do Indoscope controlled resection
16:57
So this is the value of the Indoscope that the microscope did not allow us to see natural to the PCA
17:18
And here you can see complete resection, and most importantly, here you can see the edema surrounding the lesions
17:26
in the parapacompan jars is gone. How about microsurgical, like in this case with headaches and vomiting large pineal mass, she had a PFO when we did the echo. This case was done with the
17:40
microscope
17:44
Here we can see the presenter cerebellar vein, where dissecting the tumor while protecting the presenter cerebellar vein, and after that we bring the endoscope to make sure we're not leaving any
17:58
residual, like in this case all the venous anatomy has been preserved and crystal to the excision and the mass We have zero percent mortality, but we have one case of air embolizin, one epidural
18:13
hematoma. and three Tempe-Pairnaut syndrome, and all of them recovered well after treatment. We worked with a group in Europe, amazing colleagues from Italy, France, Russian, Spain, and
18:29
Switzerland, collecting cases for the extreme lack of supercellular approach, studying the surgical anatomy. If some of the viewers are interested to look into this, both microsurgery or endoscope
18:46
endoscopic approaches for the extreme lack of supercellular approach, hopefully they'll find this paper useful. In conclusion, civic sitting position is safe and essential approach for pediatric
18:60
patients with complex pineal medial, temporary CPA lesions. It doesn't matter if we do microsurgery endoscopy. Endoscope control, the endoscope-assisted microsurgery are really useful. use when,
19:15
are very useful when we complement those techniques together and give them use for the right indication of the right patient at the right time. And at the end of the day, surgical planning and
19:28
essential partnership with colleagues with anesthesia and other specialties are essential after the anatomical knowledge and patient selection care for planning to give best outcomes possible. Thank
19:40
you Can you go back to the slide which you had, the complications after surgery, it was about six slides ahead of this list, right? No mortality, one out of
19:54
26 intraoperative area embolism. And you're talking about 28 pediatric cases, paranoid syndrome, temporary, and one epidural hematoma. Correct? Correct I'm going to show you something, if you
20:00
first of
20:07
all enjoyed that, I have some suggestions, you ready for it? Go ahead. All right, let me let me do this, the screen sharing, stop sharing.
20:21
And let
20:24
me get here. Okay, have
20:34
you ever seen this paper before? It's published in 19? I
20:38
did not, but I would love to have it. Well, this is published in 1988. We're talking about 40 years, more than 40 years ago. And at that time, I studied the literature because we had people who
20:50
were coming in with pineal region tumors. And the outcome of that surgery was a disaster. People would use a sitting position and a very good surgeon, a very well-known surgeon at the time he was
21:05
at the Lee Clinic. His name was James L. Poppin. And he has an atlas. You can look it up in the library. Poppin's atlas. And he has, and this is in the 1920s and 30s, he wrote this, he wrote
21:19
this atlas of all these different surgical procedures you do. And if you face it, that's a hundred years ago. And he was an outstanding surgeon. And he would attempt to work, it was a kind of
21:32
dandy collage. And he would work on pineal region tumors. And the reason that people didn't want to treat the tumor at the time is because they would do it In the semi-sitting position, they had
21:45
all the problems with that. And we'll talk about that in a minute. And he wound up with half of the patients getting a homonymous amionopsia because he had a retract to hemisphere. And now I'm
21:58
trying to point a picture of a man who is an outstanding neurosurgeon.
22:03
This was no lie-by-nighter. This man was a very highly regarded surgeon and he did the surgery and at that time, he had a devastating deficit. And so many people, the same, felt the same way and
22:20
pineal surgery didn't go very far. As a matter of fact, what happened, and I think I'm gonna go through some history, I'll probably catch you up with your age. And at that time, what they did is
22:33
they'd see a mask 'cause they only had ventricularography. You'd see
22:37
it in the pineal. And then they got angiography, which didn't help very much, except to tell you with God, there's too many blood vessels there. I'm not going to that area. And I don't have a
22:48
microscope. So it became a deep-seated tumor that was almost impossible at that time to take care of. And so there was a fall-off in the literature about people doing that. And then I think there
23:03
was somebody else that forgot his name, I shouldn't do that. And it was a, who started, is the approach Ben cerebellar Stein super.
23:12
Ben Stein was a neurosurgeon who was a Tufts in Boston and then went to New York. It was at Columbia for a period of time. And actually taught a
23:25
bunch of people after him. He used this
23:28
supercell railroad approach for the Pineal Region. And he had a lot of cases. And one of the things that came out of his work was you mentioned this. And it's very important for people to know
23:39
because in the interval between 1920 and the 1960s here, what people did to treat pineal region masses is they basically, and this is the same for brainstem tumors. I'm sorry to tell you all this,
23:55
but I have to do this for just perspective. What people did around the world is, and this was for brainstem tumors, you should know this as a pediatric neurosurgeon, if you didn't read it, People
24:08
would radiate the brainstem on the basis. without a pathological diagnosis. And they radiated it because it looked like it was growing in a mass and it had to be a brainstem tumor. And that's what
24:20
they did. I never bought that because I agreed with you and what you were emphasizing is you got to know what the tissue is before you do any treatment. And so nobody got tissue at that time 'cause
24:34
it was too hard to biopsy, it was too risky. Then the Japanese came out and they started treating these people in the pineal region. And in Japan, there's
24:47
a pineal tumor that is more common but is very radio sensitive. And they would treat these with a preliminary treatment of radio of, it was x-ray therapy. And if it shrunk, they would continue to
25:02
treat it because they know that they had the right diagnosis. It was a therapeutic diagnosis.
25:10
And so that's where the field was then. Ben Stein was a little bit older than I was at the time. And I sat down and I read the literature from pop and I knew about what Ben did. He did a terrific
25:21
job. And
25:25
I thought about it. And I said, this makes no sense to me. First of all, if you go above the cerebellum, one of the problems I had with that is you've got to be very careful of the cerebellum
25:37
superior draining veins There are a lot of veins there that are important. I had a patient, we did that on, didn't do very well. Because we, in order to get a cord, or we took some draining
25:48
veins, it turned out one of them was very important. So I learned a lesson. And the second thing is, and you shoot at one of your films, with your arms extended up, and your neck hyper-extended.
25:60
That's what Ben had to do. And there was no assistant who can help
26:05
you. That was the second problem Third problem is how do I get over homonemisemian opsia?
26:10
which came from retraction of the occipital lobe when they were sitting. Follow me?
26:17
And so at that point, I developed this approach to the pineal region, which is the three prawn, three quarter prawn, operated side down, which nobody thought about it at the time. And I did it
26:30
because I went home and I had a skull at home and I was saying, Look, there's gotta be a way to solve all these problems. I used to write all the problems down about a procedure and treatment of a
26:40
disease on one hand. And then I write on the next column, what can I do to eliminate all those complications? And then develop the procedure. And so you see what this does is it puts the patient,
26:52
first of all, in a reclining position.
26:57
The difficult thing here is the positioning. Now, I grew up in an age that you don't remember where we did a lot of surgery and the semi-sitting position And the problem was air embolism. And so we
27:11
would wrap the patients in something called a G-suit, which was to put pressure on the body so that if you had an open vein, it wouldn't suck the air in and they get an M-less. It turned out that
27:24
that's a real phenomenon. I was operating at the VA hospital one day and I asked Shelley Schu to come over. He was the head of neurosurgery. And he was very good at doing pain procedures by
27:37
transacting the cord to spinal thalamic tract. So he sat the patient up. This is almost a nothing operation. Sat the patient up, exposed the cervical spine where the thoracic spine where he's
27:50
gonna do this. And he made the section, patient never woke up from surgery. Why? Oh, air embarks. Air embarks, and they went and took the patient, down a radiology as head was filled with air.
28:04
I mean, there are those things you know, to happen to you in your life, do those things and you never forget it.
28:11
And so, and so to me - Tension pneumocephalus, you mean? Yes, and so to me, I had to find a different way of doing this because sitting them up, if I set up 100 cases, my chance of getting an
28:25
air embolus might've been five out of 100 or three out of 100, but it was devastating. So we use this approach and you can see what you do is you take the patient supine and you rotate him into a
28:37
lateral position, then you have to move his legs up so he's positioned properly. It's all in the paper. I'll send it to you. And you get him with the operated side down. This is the key
28:48
difference.
28:51
Then, pardon me? Yeah, so this is a certain to interrupt you. It's a variation of modified park bench. It is. And you wrote a paper, which I have right here, actually, on this, 'cause I read
29:06
this paper that you had, But in the paper, you did a lot of different approaches to difficult regions in the midline and so forth. And you talked about it. So here's what you do, and you implied
29:24
there was some implication that this is what you were doing. So as you, as if the lesion, if you wanna have, if you wanna let the occipital lobe fall away, if you put 'em in this position,
29:37
rotate the head three quarters, as I see, then you have to flex 'em, that's in five. Then you put the pins on 'em, you can do the same for a child. And then you make an opening, instead of
29:49
going above the cerebellum, you're both sitting in, using a microscope, sitting in chairs next to each other. And what you find, and you may have to put a drain in the ventricle to
30:00
allow it to fall away. It's self-retraction, so you eliminate any kind of visual loss. The second thing you do is you see, you have to cut the tintoria and you stitch it up and you are immediately
30:14
in the superior cerebellum, the vermis, the pineal region and so forth. And you can modify this and you can get to the mesial temporal lobe. If you just go suboccipital and you can still use a
30:29
non-sitting position but you can get into that immediately. We have a video on there from Argentina where they did an AVM in that region using this. So I offer this to you as a
30:41
suggestion because it sounds a lot of problems. And then you certainly, and I liked your use of, you say endoscopically assisted. I think that's very smart because the microscope has its limits,
30:56
particularly at this level of depth and you gotta use long instruments. And so then you get your endoscopic assisted surgery you've eliminated all the complications from them, and which is one of
31:10
the patients who had air envelace. And one of the things I learned from Dr. Boschnik from
31:17
Slovenia, and you probably know this, but there is a side cutting, a side cutting suction. Do you know about
31:27
that? Side cutting suction, I didn't know that. Yes, I asked him about it. We talked about it, I can find out, but what it does is as you put the suction in, rather than the tissue getting
31:39
sucked up into the head, the head is blunt and there's a rotating knife on the inside. And so gently, you just move it with some suction, and gently move through the tumor. And so I didn't have
31:54
that at the time. I thought that was a neat device, if you want, I can find out for you. So anyway - That's creative Yeah, and so. And so that was in this paper goes through this, I'll send it
32:07
to you, but that was 40 years. Most people, most people don't go back that far. But a number of people have used this. I think you'd find it helpful. And it would solve a lot of the challenging
32:22
issues you're having. You don't need to worry about error and lists or sit them up because you've got to pad everything And I went through that for maybe five years in training. We did
32:35
that. Thank you so much, Professor, for sharing this valuable history and valuable experience. You know, the controversy of prone or three-quarters prone, what if a park bench or semi-sitting or
32:52
sitting like the old days, it all depends on many factors similar to the market, the comfort and the surgeon and the team. I consider myself fortunate that I have a great anesthesia team, But in
33:04
other places, if I operate on it, I won't feel comfortable doing it. I have done modified park bench, and I have done a prone, and with the easy-tiltarial angle, prone position is not a bad idea
33:18
as well. In children, you know, I get a lot of kids who are two-year-olds. Yes, very black girls. Very black girls. Exactly, and I can't print them. Yeah. So
33:32
each case is specific, but this valuable experience you shared with me and certainly would impact my practice, and I'm looking forward to receive the paper from you. Yeah, you can do it. And kids
33:42
using the Mayfield Games comes with pediatric pins. You know that. Yeah, yes, I do, but still, some babies are - Are very small. And we had a patient where the pin penetrated the skull and it
33:55
got a little subdural collection there. So, I mean, none of us are, are perfect and we can all learn from each other. And I thought this would
34:05
be a terrific addition to what you're doing. And boy, I could have imagined
34:12
having an endoscope assista. We did another case that was very large in the pineal region. It also gives you a very good view of the vascular structure.
34:22
Because you're right there. That's what I love about the difference for endoscopy
34:28
and microsurgery. The tumor was so extensive that we couldn't get it all out through the three quarter prone approach. So we had to come back and go a pair of ventricularly and get it and so forth
34:36
and so on. So there limitations. But so I some are obviously
34:42
think what's happened is, and the other key point that you mentioned, and at the time you see people said, Well,
34:51
most of the tumors in the pineal region are malignant. Well, Ben Stein did a lot of these cases and he found two key findings.
35:01
is that the pathology that you sample at surgery may not be consistent throughout the mass. So you have to take multiple biopsies. And he did that and published it and showed that histology can
35:15
change in different parts of the tumor. So - Yeah, that's interesting. And he found
35:23
that. And then he found after taking his whole series that 30 of the pineal region lesions tumors or what they thought were tumors were benign. So people were either radiating a lesion that was
35:36
benign, which they didn't need, or leaving a goal, which they didn't need. 'Cause one out of three of them, you had at least a benign lesion at that time. We didn't have the super sensitive
35:47
chemotherapy. It was just being introduced. We did have some radiation therapy. People were just beginning to put endoscopes into the third ventricle and sample. You know, take a biopsy of the
35:59
tumor there, It couldn't do much with it. So I guess that gives us about compressed about 60 years of history. Thank you, sir, for sharing it with me. Very valuable. Okay. Well, let's hammer.
36:12
Thanks a lot. I hope the audience learned something from all this. I think it was a terrific experience. You presented great results and I know you do an outstanding job. So anyway, we learned
36:26
from each other, right? Thank you for having me, sir. I really enjoyed it. Thank you Okay. Bye-bye. Thanks again. These are the key references in the presentations that you will see. Take
36:40
screenshots. Be prepared to take screenshots for your records.
36:46
This is the reference on the three-quarter approach to the pineal region discussed in the talk on the pineal region lesions.
36:57
It was published in surgical neurology in 1988
37:01
as cited.
37:05
This is a picture which refers the patient positioning for the three-corner prone-operated side-down approach,
37:15
and this is its accommodation, allowing both the surgeon and the assistant to participate in the surgery while the patient's in basically the supine or the prone position.
37:32
We hope you enjoyed this presentation.
37:35
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This recorded session is available free on SI digital. Click on this icon at the bottom right of your home page to submit questions, comments, or requests for CME credit to SI Digital.
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The foundation supporting these journals in this presentation believes there are many ways to learn.
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SI, surgical neurology international, is a 2D internet journal with Nancy Epstein as its editor-in-chief Its web address is
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SIglobal.
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SI Digital Innovations and Learning is a 3D video journal which is interactive with lots of discussion. Its web address is SI Digitalorg and both are free on the internet 247, 365 Go to
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the National of the Journal. It's. is read in 239 countries and territories and is the third largest readership in neurosurgical journals. SI invitations and innovations in learning
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is seen in 145 countries after 11 months of publication. It's the first video neurosurgery journal. The foundation supporting these efforts and healthy people throughout the world.
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SNI Digital is now offering podcasts on Amazon, Spotify, soon on Apple, under the titleSNI Digital. All of the programs will be on podcasts for you to use globally.
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Foundation is also sponsoring and supporting a medical news network to bring truthful medical and science news to the world
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These programs are supported by James I. and Caroline Osman, Educational Foundation, All Rights are Reserved. Contact James Osman for more information.
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Thank you. We hope you've enjoyed these programs
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