1 00:00:00,080 --> 00:00:01,320 Slide, please, Gaetano. 2 00:00:01,919 --> 00:00:08,240 All right. And now we are back to our main speakers for today. 3 00:00:08,439 --> 00:00:15,880 Again, as I mentioned at the beginning, our incredible fellow team, they all have 4 00:00:15,880 --> 00:00:20,239 a number of projects ongoing and have been presenting all around the country and 5 00:00:20,239 --> 00:00:25,320 the world. So we get to hear some of their recent work that was presented at the CNS. 6 00:00:25,359 --> 00:00:28,679 And Gaetano, I think you're going to be going first. 7 00:00:28,679 --> 00:00:29,480 Is that correct? 8 00:00:31,559 --> 00:00:32,119 Yes, sir. 9 00:00:33,000 --> 00:00:33,640 All right. 10 00:00:41,240 --> 00:00:42,439 Let me share my screen. 11 00:00:58,719 --> 00:01:00,280 All right. Good morning, everyone. 12 00:01:00,479 --> 00:01:04,659 So today I'll be presenting on our initial results of precision treatment of 13 00:01:04,659 --> 00:01:09,099 postoperative CSF leaks with ultrasound-guided epidural blood patch. 14 00:01:09,340 --> 00:01:13,299 And this is a talk that I gave as an oral presentation at CNS in Austin, 15 00:01:13,299 --> 00:01:16,700 and really was a work of the entire spine team here at Mayo Clinic Florida. 16 00:01:16,700 --> 00:01:19,659 Florida, as well as Dr. Clendenon and James West. 17 00:01:24,180 --> 00:01:26,739 I don't have any disclosures relevant to this talk. 18 00:01:27,500 --> 00:01:31,340 As you know, incidental durotomy is a very well-known complication of spine 19 00:01:31,340 --> 00:01:35,780 surgery, and if left untreated, it can lead to a persistent CSF leak or 20 00:01:35,780 --> 00:01:41,459 pseudomeningocele. The reported rate of incidental durotomy ranges from 4 to 16%, 21 00:01:41,459 --> 00:01:43,299 depending on the index operation. 22 00:01:43,739 --> 00:01:47,420 If patients develop symptoms of persistent CSF leak, 23 00:01:47,420 --> 00:01:49,379 first-line treatment is bed rest. 24 00:01:49,579 --> 00:01:53,459 Other options include oversewing the wound and placement of a lumbar drain, 25 00:01:53,659 --> 00:01:58,420 and there is the potential need of having to go back to the OR for direct repair. 26 00:02:00,760 --> 00:02:06,560 While epidural blood patches are routinely used to treat post-anesthesia or post-LP CSF 27 00:02:06,599 --> 00:02:11,159 leaks, they are not often used after spine surgery for durotomy repair. 28 00:02:11,520 --> 00:02:15,479 The ultrasound is a great technique that allows radiation-free and 29 00:02:15,479 --> 00:02:18,240 direct real-time visualization of the pseudomeningocele, 30 00:02:18,240 --> 00:02:19,719 the dura, and the Tuohy needle. 31 00:02:19,919 --> 00:02:23,639 But this application in the native spine is often very limited. 32 00:02:24,000 --> 00:02:26,560 That's magnified in the postoperative spine, 33 00:02:26,599 --> 00:02:31,599 thanks to the bone work that has been done by removing the bony anatomy and the ligamentous 34 00:02:31,599 --> 00:02:35,400 there, which allows a window for the ultrasound and for the needle to be 35 00:02:35,400 --> 00:02:41,520 visualized properly. So in our study, we did a retrospective analysis of patients 36 00:02:41,520 --> 00:02:46,439 that underwent the US EBP at Mayo Clinic Florida from 2009 to 2020 37 00:02:46,479 --> 00:02:50,280 for symptomatic pseudomeningocele secondary to spine surgery. 38 00:02:50,319 --> 00:02:54,039 We collected demographic, procedural, and outcome characteristics. 39 00:02:54,560 --> 00:02:58,319 The primary outcome of our study was ultrasound EBP success, 40 00:02:58,520 --> 00:03:02,939 defined as a resolution of the initial symptom that brought the pseudomeningocele to clinic. 41 00:03:02,979 --> 00:03:05,740 clinical attention, such as postural headaches, 42 00:03:05,740 --> 00:03:11,460 incisional leak. For our technique, patients are positioned prone. 43 00:03:11,500 --> 00:03:14,659 The ultrasound is used to localize the pseudomeningocele, 44 00:03:14,819 --> 00:03:19,740 and the color Doppler can also be adopted to determine if there are any active sites of 45 00:03:19,780 --> 00:03:23,699 CSF leak of egress. Under ultrasound guidance, 46 00:03:23,740 --> 00:03:28,580 An 18-gauge Tuohy needle is advanced into the pseudomeningocele and the content is 47 00:03:28,580 --> 00:03:32,659 aspirated. The needle is then advanced into the epidural space, 48 00:03:32,659 --> 00:03:38,379 and about 30 mL of autologous blood is injected epidurally in 5 to 10 mL aliquots 49 00:03:38,379 --> 00:03:40,539 under continuous ultrasound guidance. 50 00:03:41,180 --> 00:03:45,379 Then, after waiting for 5 to 10 minutes to allow the blood patch to set, 51 00:03:45,699 --> 00:03:49,979 The ultrasound is then used again to confirm the placement of the patch, and the color 52 00:03:49,979 --> 00:03:54,860 Doppler can also be used to confirm an absence of CSF egress if that was previously 53 00:03:54,860 --> 00:04:00,689 identified. Overall, we had 48 patients who underwent a total 54 00:04:00,689 --> 00:04:07,210 of 61 US EBPs. And you can see that the most frequent index operation was a laminectomy, 55 00:04:07,250 --> 00:04:13,530 24.5%, and about 36.7% of these cases were revision surgeries. 56 00:04:14,289 --> 00:04:20,170 And also that the incidental durotomy was unrecognized during the surgery in about 22% 57 00:04:20,170 --> 00:04:29,569 of cases. You can see here that the median time from surgery to symptom development was 58 00:04:29,569 --> 00:04:33,970 seven days, and the most frequent symptoms at presentation were 59 00:04:33,970 --> 00:04:40,449 postural headaches in 64% of cases and incisional leak in 26.5% of cases. 60 00:04:42,009 --> 00:04:46,009 Here, looking at the results of the EBP under ultrasound guidance, 61 00:04:46,009 --> 00:04:51,290 You can see that 51% of patients experience resolution of their symptoms after their first 62 00:04:51,290 --> 00:04:55,930 blood patch, and you can see that the median volume aspirated from the pseudomeningocele 63 00:04:55,930 --> 00:05:02,910 was 34 mL, and also that another 20% of patients experience resolution of their 64 00:05:02,910 --> 00:05:06,110 symptoms after subsequent attempts of blood patches. 65 00:05:08,629 --> 00:05:13,990 Talking about complications, we had about 14% complications in our series, 66 00:05:13,990 --> 00:05:17,110 And the most frequent one was wound infection in two patients, 67 00:05:17,149 --> 00:05:19,509 followed by meningitis also in two patients. 68 00:05:21,629 --> 00:05:24,350 Here is a couple of illustrative cases you can see here. 69 00:05:24,389 --> 00:05:26,709 Patient that presented with a dural AV fistula. 70 00:05:26,990 --> 00:05:32,269 And here on the T2 sagittal MRI you can see a fairly large pseudomeningocele. 71 00:05:32,629 --> 00:05:35,990 After the patient had undergone the laminectomy and obliteration of the AV 72 00:05:36,029 --> 00:05:39,949 fistula, the patient underwent an ultrasound epidural blood patch. 73 00:05:39,949 --> 00:05:43,949 The contents of the pseudomeningocele was aspirated and a blood patch placed. 74 00:05:43,949 --> 00:05:46,110 And then you can see on the postoperative MRI, 75 00:05:46,149 --> 00:05:50,110 sagittal and axial cut that was done one month after the procedure. 76 00:05:50,110 --> 00:05:52,509 complete resolution of the pseudomeningocele. 77 00:05:54,709 --> 00:05:57,509 This is another case of a patient that laminectomy, 78 00:05:57,509 --> 00:06:01,889 as you can see here on the CT scan on the level above a previous fusion construct, 79 00:06:01,889 --> 00:06:05,850 and there is an hypodensity there, a collection, fluid collection, 80 00:06:05,850 --> 00:06:09,769 that was also again identified under the ultrasound where you can see the star there, 81 00:06:10,009 --> 00:06:14,290 And then the color Doppler was used to identify the active CSF egress there. 82 00:06:15,009 --> 00:06:18,329 The Tuohy needle, you can see here in white where this big arrow is, 83 00:06:18,449 --> 00:06:21,529 is inserted. The content of the pseudomeningocele is aspirated, 84 00:06:21,529 --> 00:06:25,050 as you can see in figure E, and then the blood patch is placed. 85 00:06:25,769 --> 00:06:28,810 And this is a postoperative scan that documents resolution of the 86 00:06:28,810 --> 00:06:34,329 pseudomeningocele. Our study carries all the limitations of all single-institution 87 00:06:34,329 --> 00:06:35,889 retrospective studies, 88 00:06:35,889 --> 00:06:40,370 therefore further prospective and multicenter studies are needed to confirm the 89 00:06:40,370 --> 00:06:42,569 generalizability of our data. 90 00:06:42,970 --> 00:06:48,649 But our study is the first and the largest series describing the adoption of US EBP in 91 00:06:48,649 --> 00:06:52,930 in patients presenting with persistent pseudomeningocele and CSF leak 92 00:06:52,930 --> 00:06:58,129 following spine surgery. We found an overall success rate of over 70%, 93 00:06:58,170 --> 00:07:01,269 with a first-attempt success rate of 50%. 94 00:07:01,670 --> 00:07:06,750 So this suggests that the utilization of US-guided EBP in expert hands may allow for 95 00:07:06,750 --> 00:07:10,629 targeted treatment of a large portion of symptomatic postoperative 96 00:07:10,670 --> 00:07:13,470 pseudomeningoceles. Thank you. 97 00:07:18,069 --> 00:07:19,230 Gaetano, that's excellent work. 98 00:07:19,230 --> 00:07:25,029 Congratulations. It's a novel treatment for these non-uncommon problems. 99 00:07:25,269 --> 00:07:28,350 One thing that I realized I never asked Dr. Miller or 100 00:07:28,350 --> 00:07:33,550 Dr. Clendenon: what's the consistency of the blood that you're using as the patch, 101 00:07:33,550 --> 00:07:38,790 And how long is it in between obtaining the autologous blood and actually injecting it? 102 00:07:40,949 --> 00:07:46,029 I don't know about the time between when the blood is drawn and injected, sir, 103 00:07:46,509 --> 00:07:50,509 but most of them, I believe, it may have been done at the same time of the 104 00:07:50,509 --> 00:07:51,509 procedure, sir. 105 00:07:52,069 --> 00:07:56,269 Yeah, but I mean, they aspirate it and then immediately give it. 106 00:07:56,310 --> 00:07:59,189 I was just curious about how thick the blood is. Maybe 107 00:07:59,850 --> 00:08:02,490 Elird, I see Dr. Behrakis who might 108 00:08:03,009 --> 00:08:05,449 Yeah, I do some of these as well. 109 00:08:05,490 --> 00:08:08,569 Okay. Yeah, we go right away for the blood. 110 00:08:08,610 --> 00:08:11,970 So it's right from an IV catheter into the epidural space. 111 00:08:11,970 --> 00:08:15,050 What's really helpful is the Tisseel fibrin glue. 112 00:08:15,370 --> 00:08:20,209 So it's human fibrin blood components that we inject, 113 00:08:20,209 --> 00:08:23,970 and that solidifies much, much quicker and is much more firm. 114 00:08:23,970 --> 00:08:26,930 With the blood, it's thinner and can get into different 115 00:08:26,930 --> 00:08:29,730 crevices, while the fibrin glue is a bit more firm. 116 00:08:29,730 --> 00:08:32,570 So you try to get both properties in there right at the leak. 117 00:08:32,929 --> 00:08:34,049 Excellent. Yeah. Thanks. 118 00:08:34,049 --> 00:08:35,330 Thanks, Tiana, I appreciate that. 119 00:08:35,649 --> 00:08:37,730 Alireza, did you want to give—I see your hand up there. 120 00:08:37,730 --> 00:08:39,090 Do you want to make a comment? 121 00:08:40,649 --> 00:08:42,970 Sorry I can't join on camera because I'm 122 00:08:42,970 --> 00:08:46,649 tied up in the hospital. 123 00:08:47,730 --> 00:08:51,370 But I would like to second those comments. 124 00:08:51,370 --> 00:08:54,690 I've done a couple of these cases with Dr. Clendenon. A lot of times what we do is we 125 00:08:54,690 --> 00:08:55,850 place an arterial line. 126 00:08:55,850 --> 00:09:02,470 So that way we can reliably draw blood right away as soon as access is identified with the 127 00:09:02,470 --> 00:09:06,470 ultrasound machine. Fibrin glue has also been something new 128 00:09:06,509 --> 00:09:09,190 that's been very helpful for these cases. 129 00:09:10,110 --> 00:09:14,950 One question that I had, and this is something that we always worry about, is the risk of 130 00:09:14,950 --> 00:09:16,789 infection and meningitis. 131 00:09:16,789 --> 00:09:18,909 And it's interesting from the data presented, 132 00:09:18,909 --> 00:09:20,590 that was about two, I believe. 133 00:09:22,789 --> 00:09:26,509 Any thoughts on looking at the data and anything that we can 134 00:09:26,509 --> 00:09:29,990 do to make things better or reduce that risk? 135 00:09:29,990 --> 00:09:34,629 Or is this contributed directly to the block itself? 136 00:09:34,669 --> 00:09:38,629 Or were there other circumstances on those two patients that got infections? 137 00:09:39,389 --> 00:09:39,950 Thank you. 138 00:09:40,750 --> 00:09:45,549 Yes, sir. Excellent question. We had about two patients, about 4% for 139 00:09:45,549 --> 00:09:49,509 our series. It's a small series, so it's difficult to generalize if that's 140 00:09:49,509 --> 00:09:52,110 really a 4% for the procedure itself. 141 00:09:52,269 --> 00:09:54,830 But that was assumed to be related, it was meningitis, 142 00:09:54,830 --> 00:09:59,210 assumed to be related to the procedure, not like a UTI or any other infections. 143 00:10:06,330 --> 00:10:12,730 Let's see. We have a question from Dr. Vargas about what 144 00:10:12,769 --> 00:10:17,049 about the presence of fibrous tissue after the procedure? 145 00:10:17,090 --> 00:10:17,970 And I think 146 00:10:18,009 --> 00:10:19,570 So these are usually done 147 00:10:19,610 --> 00:10:21,690 in scar, that sort of thing. 148 00:10:22,610 --> 00:10:27,210 Yeah, so these are usually done right after the procedure, it's not too long. 149 00:10:27,210 --> 00:10:30,570 And that's why it's very difficult to do them anatomically guided. 150 00:10:30,570 --> 00:10:34,250 That's why the ultrasound really helps to visualize the anatomy. 151 00:10:34,450 --> 00:10:39,009 And as far as we didn't have any issues as far as going through fibrous tissue for 152 00:10:39,009 --> 00:10:39,649 the patches. 153 00:10:41,970 --> 00:10:43,570 Great. Well, thank you so much, Gaetano. 154 00:10:44,009 --> 00:10:48,049 A couple more points here. 155 00:10:48,049 --> 00:10:52,450 Dr. Dean mentioned, would emphasize the need to make sure patient is afebrile and has 156 00:10:52,450 --> 00:10:55,690 normal white blood cell count prior to the blood patch. 157 00:10:55,730 --> 00:10:59,509 I know that's part of the protocol and a good point. 158 00:10:59,509 --> 00:11:02,870 Some of these patients are immediate post-op. 159 00:11:03,190 --> 00:11:06,269 They have an immediate postoperative status, so they might have an elevated white blood 160 00:11:06,269 --> 00:11:07,950 cell count just from surgery. 161 00:11:09,669 --> 00:11:11,669 Very, very good point. 162 00:11:12,509 --> 00:11:16,389 All right. Excellent work, Gaetano. 163 00:11:16,750 --> 00:11:19,870 And we will go on to the next presentation. 164 00:11:22,909 --> 00:11:27,509 We have Dr. Garcia who is going to be presenting next. 165 00:11:28,549 --> 00:11:29,750 Can you see this, Dr. Fox? 166 00:11:30,190 --> 00:11:30,830 Yes. 167 00:11:31,909 --> 00:11:33,710 It's advancing by itself. 168 00:11:34,350 --> 00:11:36,190 All right. Good morning, everyone. 169 00:11:36,190 --> 00:11:40,629 Today I'm going to be presenting on SPECT CT as a predictor of pain generators in patients 170 00:11:40,629 --> 00:11:43,789 undergoing intra-articular injections for neck and back pain. 171 00:11:44,110 --> 00:11:46,509 I think most of you already know of this project. 172 00:11:46,509 --> 00:11:49,830 It's a project that we did with the spine group under particular mentorship of 173 00:11:49,870 --> 00:11:55,110 Dr. Abode-Iyamah, and we presented it at Austin at the Congress of Neurological Surgeons. 174 00:11:55,110 --> 00:11:57,950 As you know, low back pain and also neck pain, 175 00:11:57,950 --> 00:12:02,139 but there's a lot more literature on low back pain, is one of the main leading causes of 176 00:12:02,139 --> 00:12:07,019 disability in general, and yet the identification of painful 177 00:12:07,019 --> 00:12:08,500 generators is still difficult. 178 00:12:08,500 --> 00:12:12,820 Despite use of multiple morphological-based studies, 179 00:12:12,820 --> 00:12:18,620 including X-ray, CT, MRI, and also compounded by the fact that sometimes structural 180 00:12:18,620 --> 00:12:23,220 abnormalities found on scans have no direct correlation with the actual 181 00:12:23,220 --> 00:12:27,340 pain of the patient, which makes the correct identification of the painful generator 182 00:12:27,340 --> 00:12:32,019 difficult and therefore the targeted treatment for that painful generator also 183 00:12:32,019 --> 00:12:33,259 difficult and limited. 184 00:12:33,419 --> 00:12:38,899 With this in mind, there has been some interest in functional-based tests like SPECT 185 00:12:39,259 --> 00:12:42,659 to accurately identify those painful generators, 186 00:12:42,940 --> 00:12:47,740 More recently, a scan has been available which is called the hybrid SPECT CT, 187 00:12:48,340 --> 00:12:53,179 which at Mayo we have been fortunate to have available for a number of years and with good 188 00:12:53,179 --> 00:12:56,019 quality, as I'm going to show in one of the example scans. 189 00:12:56,179 --> 00:13:00,080 So the idea here was to look at facet joint injections, 190 00:13:00,080 --> 00:13:05,919 targeted injections, and see whether or not the hypothesis that injections targeted at 191 00:13:05,919 --> 00:13:11,600 positive sites of uptake would do better than injections targeted at foci without uptake. 192 00:13:11,840 --> 00:13:15,000 To accomplish this, we designed a study with a single institution 193 00:13:15,000 --> 00:13:19,919 retrospective in which we compared both short and long-term outcomes for patients 194 00:13:19,919 --> 00:13:22,919 undergoing facet joint injections for neck and back pain. 195 00:13:23,639 --> 00:13:26,879 Given the large sample size, I was able to do a propensity score match 196 00:13:26,879 --> 00:13:29,720 to adjust for age, gender, BMI, hypertension, 197 00:13:29,720 --> 00:13:32,799 and multiple target injections and injection location. 198 00:13:32,799 --> 00:13:37,960 We did exclude sacroiliac joint injections, given that they are a bit different and they 199 00:13:37,960 --> 00:13:43,639 should not be grouped all the same with cervical, thoracic, and lumbar injections. 200 00:13:43,840 --> 00:13:45,440 So these were our main outcomes. 201 00:13:45,440 --> 00:13:50,799 We looked at immediate positive response, change in VAS two weeks after injection, 202 00:13:51,320 --> 00:13:56,720 improvement in VAS above 50 and 70% after injection, and need for additional treatment, 203 00:13:56,720 --> 00:13:58,379 both injection and surgery. 204 00:13:58,779 --> 00:14:03,139 Importantly, at Mayo, we have people who do call these patients two 205 00:14:03,139 --> 00:14:07,460 weeks after the procedure who are not implicated in the research. 206 00:14:07,460 --> 00:14:11,779 So they're able to give us unbiased feedback from the patient regarding patient- 207 00:14:11,779 --> 00:14:16,259 reported outcomes, which allowed us to really objectify these outcomes. 208 00:14:16,379 --> 00:14:19,139 So as you can see, we have a large number of patients, 209 00:14:19,139 --> 00:14:24,700 2,849 patients that were evaluated with SPECT CT within five years. 210 00:14:24,980 --> 00:14:30,899 Out of these ones, we had 340 with facet injections within 150 days after a SPECT CT. 211 00:14:31,179 --> 00:14:33,700 Why 150 days? We had to choose a threshold. 212 00:14:33,779 --> 00:14:37,620 There is no specific literature on the threshold. 213 00:14:37,620 --> 00:14:41,740 We just had to come up with a threshold that would allow us to look at outcomes that were 214 00:14:41,740 --> 00:14:45,059 associated with the injection and not associated with something else that could 215 00:14:45,100 --> 00:14:46,940 have happened in the interlude. 216 00:14:47,100 --> 00:14:50,500 We had a total of 140 cervical injections, 217 00:14:50,500 --> 00:14:54,179 21 thoracic injections, and 207 lumbar injections. 218 00:14:54,379 --> 00:14:58,600 Importantly, 265 were uptake-targeted injections. 219 00:14:58,600 --> 00:15:01,840 By this we mean that all the injections were targeted at foci of uptake, 220 00:15:01,840 --> 00:15:04,559 all of them. That was our definition of uptake. 221 00:15:04,600 --> 00:15:08,480 targeted injections and 75 were non-uptake targeted injections. 222 00:15:08,639 --> 00:15:11,759 So as you can see here, just an example of a SPECT CT at Mayo, 223 00:15:12,440 --> 00:15:18,720 with in this particular patient, a right L4-L5 facet joint having uptake that was 224 00:15:18,720 --> 00:15:22,840 targeted by injection. This is actually one of the cases that was included in this study. 225 00:15:23,120 --> 00:15:26,960 So here, just some demographics and characteristics of the location and 226 00:15:26,960 --> 00:15:28,639 characteristics of the injection. 227 00:15:28,639 --> 00:15:32,080 As you can see, even though there's nothing that is statistically significant, 228 00:15:32,399 --> 00:15:36,480 it can always compound and have an effect, a confounding effect on the variables. 229 00:15:36,679 --> 00:15:41,360 Hence why we did the propensity score match to adjust for all these variables. 230 00:15:41,480 --> 00:15:46,440 And what you can see here is that both on a univariate analysis and a multivariate 231 00:15:46,440 --> 00:15:52,559 analysis, we did not find statistically significant differences between non-uptake 232 00:15:52,600 --> 00:15:54,399 and uptake-targeted injections. 233 00:15:54,399 --> 00:15:59,539 But when we did look at patients who already had a failed injection before the SPECT CT 234 00:15:59,820 --> 00:16:04,500 and in which the surgeon or proceduralist was able to change the target based on 235 00:16:04,500 --> 00:16:05,940 the information of the SPECT CT. 236 00:16:06,299 --> 00:16:10,179 Below, what you can see is that in those patients we do have a benefit. 237 00:16:10,179 --> 00:16:14,620 And the benefit was particularly greater if there was any change made on the target. 238 00:16:14,779 --> 00:16:19,860 So that is very suggestive that for a particular set of patients with adequate 239 00:16:19,860 --> 00:16:25,620 patient selection, you do see a benefit with SPECT CT to guide facet joint injections. 240 00:16:25,899 --> 00:16:32,779 So basically our conclusions seem to support that, pending adequate patient selection, 241 00:16:32,860 --> 00:16:37,539 SPECT CT has a benefit in guiding facet injections. 242 00:16:37,659 --> 00:16:40,019 There are limitations, of course, with our retrospective single 243 00:16:40,019 --> 00:16:43,620 institution study, but we did use a propensity score to match for confounding 244 00:16:43,620 --> 00:16:48,100 variables. We have a large sample size, but of course future directions would have to 245 00:16:48,100 --> 00:16:54,259 be prospective, multi-site, hopefully double-blind clinical trial to 246 00:16:54,299 --> 00:17:00,559 to accurately discern the impact of SPECT CT in routine clinical practice. And I'll take any 247 00:17:00,559 --> 00:17:01,200 questions. 248 00:17:08,359 --> 00:17:11,799 Excellent, Diogo. Really fabulous work. 249 00:17:11,799 --> 00:17:19,039 And I think this is there's so much potential applicability to using imaging 250 00:17:19,039 --> 00:17:22,599 biomarkers for better delineating patients' pain. 251 00:17:23,680 --> 00:17:29,000 Even with the precision of these SPECT 252 00:17:29,000 --> 00:17:34,680 studies, it shows how challenging it can be to figure out pain generators in the spine. 253 00:17:34,680 --> 00:17:40,440 And I think this is incredible work with a lot of promise. Based on what you've seen so 254 00:17:40,440 --> 00:17:42,359 far, who do you think? 255 00:17:42,400 --> 00:17:45,440 Do you think we should be doing this more or less? 256 00:17:45,440 --> 00:17:47,960 Or do you think people should have this upfront? 257 00:17:48,000 --> 00:17:52,400 How do you recommend we use this based on your knowledge of the technique in 258 00:17:52,400 --> 00:17:53,640 our everyday practice? 259 00:17:54,480 --> 00:17:58,900 So the patients that I did see have a benefit were patients in which there had already 260 00:17:58,900 --> 00:18:01,059 been an attempt at an injection. 261 00:18:01,059 --> 00:18:06,380 Because my understanding is that SPECT CT is sensitive but not necessarily specific. 262 00:18:06,380 --> 00:18:10,740 So it's difficult to figure out which of those facets that are lighting up are the ones 263 00:18:10,740 --> 00:18:12,579 that are actually causing pain. 264 00:18:12,579 --> 00:18:15,940 So when we have the benefit of having a patient that already had a procedure that 265 00:18:15,940 --> 00:18:19,460 failed, we do know which of those joints did light up. 266 00:18:19,460 --> 00:18:21,740 but they're not the actual pain generator. 267 00:18:21,740 --> 00:18:24,539 So we can take those out and pursue the next ones. 268 00:18:24,539 --> 00:18:29,460 So I do see SPECT CT not as a necessary first line for any patient that has a first 269 00:18:29,460 --> 00:18:32,539 procedure, but for a recurrent facet injection. 270 00:18:32,539 --> 00:18:35,220 For a patient who has not benefited from a facet injection, 271 00:18:35,220 --> 00:18:37,420 I would definitely see benefit there. But of course, 272 00:18:37,460 --> 00:18:42,500 I think to actually make a recommendation, we'd have to have a double-blind clinical 273 00:18:42,500 --> 00:18:46,500 trial so we can make a recommendation. Hopefully coming. 274 00:18:47,220 --> 00:18:47,740 Hopefully so. 275 00:18:47,740 --> 00:18:51,740 Yeah, and we'll continue to learn more about these imaging biomarkers. 276 00:18:51,740 --> 00:18:53,380 which I think will be very helpful. 277 00:18:53,380 --> 00:18:57,289 Dr. Deen makes a great point in the comments as well that we have extremely high 278 00:18:57,289 --> 00:19:00,049 quality SPECT studies at Mayo, which 279 00:19:00,089 --> 00:19:03,170 I completely agree. At UF, we didn't do this at all. 280 00:19:03,170 --> 00:19:05,690 So this was something novel to me. 281 00:19:05,730 --> 00:19:09,289 seeing here and very impressed with the quality of these studies. 282 00:19:09,289 --> 00:19:12,529 Excellent work. All right. 283 00:19:12,529 --> 00:19:17,250 I think we can move on now to our next presentation. 284 00:19:18,490 --> 00:19:23,049 Dr. Vivas Buitrago, who is going to be speaking about supra- 285 00:19:23,049 --> 00:19:28,130 marginal resection impact on overall survival for IDH wild-type glioblastoma. 286 00:19:29,609 --> 00:19:31,130 Perfect. Can you hear me now? 287 00:19:31,650 --> 00:19:33,130 Yes. Yes. Thank you, Diogo. 288 00:19:34,170 --> 00:19:36,730 Let me share the screen here. 289 00:19:38,490 --> 00:19:40,009 All right. Are you seeing my slide? 290 00:19:40,769 --> 00:19:41,329 Yes. 291 00:19:42,210 --> 00:19:48,529 Perfect. Good morning, everyone. 292 00:19:48,529 --> 00:19:50,849 Thank you for attending to this lecture today. 293 00:19:52,170 --> 00:19:57,750 So I'm going to present our study that we presented in October this year in CNS. 294 00:19:58,430 --> 00:20:02,549 The title of this study is Supramarginal Resection Impact on Overall Survival for IDH wild-type 295 00:20:03,309 --> 00:20:06,869 glioblastoma according to their cell density distribution infiltration profile. 296 00:20:07,309 --> 00:20:08,750 This is a mathematical model. 297 00:20:11,710 --> 00:20:14,309 We have no disclosures for this lecture. 298 00:20:14,509 --> 00:20:17,990 A bit of background regarding the extent of resection in glioblastoma. 299 00:20:19,390 --> 00:20:25,549 We know that not long ago, the most common surgical recommendation for glioblastoma was 300 00:20:25,549 --> 00:20:26,950 to perform only a biopsy. 301 00:20:26,950 --> 00:20:30,150 And this was not only in the United States but worldwide. 302 00:20:30,190 --> 00:20:37,230 Since the 2000s, we started seeing very important studies from Dr. Lacroix, 303 00:20:38,789 --> 00:20:43,910 from Dr. McGirt, from Dr. Sanai, from UCSF with Dr. Berger, 304 00:20:43,950 --> 00:20:48,950 and from Dr. Chaichana and Dr. Quiñones. 305 00:20:48,990 --> 00:20:55,589 With this data from Hopkins, all of these studies were in favor of performing more 306 00:20:55,690 --> 00:20:59,369 extensive surgical resection on patients with glioblastoma, 307 00:20:59,890 --> 00:21:03,450 and the results were pretty much homogeneous, 308 00:21:03,450 --> 00:21:12,609 identifying that resections above 78% of the contrast enhancement in T1 were associated with 309 00:21:12,609 --> 00:21:18,609 a significant improvement in overall survival in patients with GBM. 310 00:21:20,529 --> 00:21:27,769 But furthermore, we see that the gross total resection is a 311 00:21:27,809 --> 00:21:33,890 is this complete surgical resection of the contrast-enhancing component of the 312 00:21:33,890 --> 00:21:35,529 tumor that you can see up here. 313 00:21:36,009 --> 00:21:42,369 But what about the FLAIR component in the T2 sequence? That we have known for 314 00:21:42,410 --> 00:21:47,769 a while already that there are infiltrated GBM cells within the brain tissue 315 00:21:48,289 --> 00:21:53,529 that most of the time is not being taken care of, 316 00:21:53,569 --> 00:22:01,430 resected because of the infiltrated behavior of these 317 00:22:01,470 --> 00:22:05,470 cells within functional brain tissue that if you resected it, 318 00:22:05,470 --> 00:22:09,509 you can cause a deficit in the functionality of the patient. 319 00:22:09,910 --> 00:22:16,029 So we aim with our group at Mayo Clinic to start looking at the extent of the 320 00:22:16,069 --> 00:22:21,309 supramarginal resection beyond the margins of the contrast-enhancing tumor. 321 00:22:21,509 --> 00:22:27,670 We have seen that regarding this topic, that has been influenced by the 322 00:22:27,670 --> 00:22:34,069 results from the good results from external resection beyond 323 00:22:34,069 --> 00:22:37,309 the margins in low-grade gliomas. 324 00:22:37,309 --> 00:22:40,950 We see here very important papers from MD Anderson, 325 00:22:40,950 --> 00:22:45,990 from Hopkins, from Cleveland Clinic, and from UCSF. 326 00:22:46,589 --> 00:22:50,869 And not all of them have homogeneous results, 327 00:22:51,069 --> 00:22:59,210 as we found before in the gross total resection for the T1 contrast. 328 00:22:59,529 --> 00:23:00,970 So we wanted to give it a shot. 329 00:23:01,210 --> 00:23:07,369 And thanks to all the data that we have at Mayo Clinic with the 330 00:23:07,369 --> 00:23:09,650 high flow of patients, we were. 331 00:23:09,690 --> 00:23:16,769 We were able to do this study in which we identified more than 800 patients. 332 00:23:16,769 --> 00:23:20,890 And we selected only those patients that were IDH wild-type, 333 00:23:20,890 --> 00:23:28,089 since it's the most aggressive type of GBM that has a less overall survival in total. 334 00:23:28,170 --> 00:23:35,849 So we only selected those patients that had a gross total resection of the contrast 335 00:23:35,849 --> 00:23:43,410 enhancement and that they did present before the surgery with some degree of preoperative 336 00:23:43,970 --> 00:23:48,009 So in total, we included 101 patients. 337 00:23:48,250 --> 00:23:54,170 We performed all volumetric analysis on all the sequences in the 338 00:23:54,210 --> 00:23:59,549 contrast enhancement, in the necrosis part, and in the FLAIR for all the patients. 339 00:24:01,269 --> 00:24:07,349 And we did find in univariate and multivariate analysis that increasing SMR as 340 00:24:07,349 --> 00:24:12,069 a continuous variable, for the first time we can show that it is statistically 341 00:24:12,069 --> 00:24:18,150 significant for an increase and improved overall survival in our patient population. 342 00:24:18,430 --> 00:24:21,509 Furthermore, when we performed a threshold analysis, 343 00:24:21,549 --> 00:24:28,990 we found that those resections above 20% and less than 60% were the ones that were related 344 00:24:28,990 --> 00:24:32,470 with a significant increase in overall survival. 345 00:24:33,670 --> 00:24:38,869 So to summarize our findings, we did this illustration that shows 346 00:24:38,869 --> 00:24:42,869 In the green part, in the green portion, are the 347 00:24:42,869 --> 00:24:47,990 percentages from above 20 and less than 60% that were related with an improved overall 348 00:24:47,990 --> 00:24:53,910 survival. And we didn't find a significant benefit in those resections above 60%, 349 00:24:53,950 --> 00:24:56,529 that is the red portion of the figure here. 350 00:24:58,130 --> 00:25:04,369 So now we know that increasing SMR is beneficial for an 351 00:25:04,369 --> 00:25:09,329 improved overall survival in our patients with IDH wild-type GBM. 352 00:25:09,650 --> 00:25:15,730 But we know that there is also a high variability in the radiological presentation 353 00:25:15,769 --> 00:25:20,250 of our group in general in GBM, but also in IDH wild-type. 354 00:25:20,690 --> 00:25:24,410 So we partnered with the Mathematical Neuro-oncology Laboratory at Mayo Clinic Arizona, 355 00:25:24,410 --> 00:25:33,130 with Dr. Kristin Swanson to try to further personalize the 356 00:25:33,170 --> 00:25:41,930 to try to be more specific with using specific patient characteristics from 357 00:25:41,930 --> 00:25:43,369 the radiological data. 358 00:25:43,369 --> 00:25:48,210 And we can see that following our hypothesis at the center of the 359 00:25:48,250 --> 00:25:54,410 lesion, the one that is in close proximity with 360 00:25:54,410 --> 00:26:00,950 the contrast enhancement part has a greater tumor burden cell concentration over there. 361 00:26:00,950 --> 00:26:05,390 And once you are going to the periphery, you see that the density 362 00:26:05,390 --> 00:26:08,630 of these tumor cells is lower. 363 00:26:09,789 --> 00:26:13,869 So this is the formula that was used in our patient population. 364 00:26:14,509 --> 00:26:19,309 In summary, for the interest of time, you can see that in the T1 with contrast, the 365 00:26:19,309 --> 00:26:22,309 volume was approximated to a spherical shape. 366 00:26:22,670 --> 00:26:30,509 And we saw that this portion has a greater cell density compared to the 367 00:26:30,549 --> 00:26:33,430 cell density in the T2 FLAIR. 368 00:26:33,910 --> 00:26:39,069 So with these results, we classified our patient population in three 369 00:26:39,069 --> 00:26:41,829 groups that were nodular, moderately diffuse, 370 00:26:41,829 --> 00:26:46,109 and highly diffuse according to their 371 00:26:46,150 --> 00:26:49,390 to their tumor cell density and distribution profile. 372 00:26:51,950 --> 00:26:57,140 So this is a representation from some of the patients that were selected and classified 373 00:26:57,140 --> 00:26:58,900 and included in these three groups. 374 00:26:58,940 --> 00:27:04,819 You can see here in the nodular, they have more contrast enhancement than FLAIR. 375 00:27:04,819 --> 00:27:09,059 And see in the moderate diffuse, you see that there is some more FLAIR in 376 00:27:09,099 --> 00:27:16,019 the patients surrounding the post-gadolinium T1, and in the highly diffuse 377 00:27:16,019 --> 00:27:19,700 you see that the FLAIR is greater than in the other groups. 378 00:27:21,859 --> 00:27:26,339 So for this, in the univariate analysis, we saw that this was significant, 379 00:27:26,339 --> 00:27:32,180 statistically significant only for moderate and diffuse and highly diffuse. 380 00:27:32,220 --> 00:27:34,980 But it was not significant for nodular. 381 00:27:35,059 --> 00:27:40,220 This is in univariate, and the same results were obtained for the multivariate analysis. 382 00:27:40,500 --> 00:27:44,579 It was statistically significant for moderately and highly diffuse, not for nodular. 383 00:27:44,579 --> 00:27:52,980 But when we performed a threshold analysis, we saw that for the nodular, there is actually a 384 00:27:53,019 --> 00:27:57,720 benefit only in resections from 80 to 100%. 385 00:27:58,240 --> 00:28:01,000 And this is kind of logical because 386 00:28:01,039 --> 00:28:04,359 In the nodular, there is not much FLAIR, as we showed you in the 387 00:28:04,400 --> 00:28:13,200 MRI before. So there is not much benefit in extending resection beyond the 20% 388 00:28:13,200 --> 00:28:16,640 of the contrast enhancement in the nodular group. 389 00:28:17,119 --> 00:28:22,839 In the moderately diffuse, we found benefits from all the way up to 50%, 390 00:28:22,880 --> 00:28:25,440 as you can see here. And in the highly diffuse, 391 00:28:25,440 --> 00:28:32,039 We only saw benefits beyond 30% all the way up to 90 and 90 plus percent. 392 00:28:33,599 --> 00:28:36,880 So this is very important because now we can, 393 00:28:37,400 --> 00:28:40,119 based on this study, at least in these results, 394 00:28:40,279 --> 00:28:44,599 we see that there is a very important benefit in the 395 00:28:44,640 --> 00:28:47,039 supramarginal resection of these patients. 396 00:28:47,039 --> 00:28:54,279 And of course, based on their radiological characteristics before the surgery, 397 00:28:54,660 --> 00:28:59,579 the surgeons can decide how much the patients can need, 398 00:28:59,579 --> 00:29:02,819 a resection, an extent of resection based on this. 399 00:29:02,819 --> 00:29:05,619 And for example, in these highly diffuse tumors, 400 00:29:05,619 --> 00:29:12,259 we found that this is the maximum SMR correlated with a beneficial overall 401 00:29:12,259 --> 00:29:19,500 survival. You can see that the patients that had a resection above 90% had a 402 00:29:19,500 --> 00:29:22,819 better overall survival than the ones that had less than 90%. 403 00:29:23,140 --> 00:29:27,220 And this patient population had a greater survival of, 404 00:29:27,940 --> 00:29:33,779 if I remember correctly, almost nine months greater than the patients 405 00:29:33,779 --> 00:29:39,500 that had a resection with less than 90%. For the moderately diffuse, 406 00:29:39,539 --> 00:29:42,779 The highest SMR percentage was 50, 407 00:29:43,099 --> 00:29:48,059 and this patient presented with a benefit 408 00:29:48,299 --> 00:29:49,980 of an additional seven months. 409 00:29:51,420 --> 00:29:55,099 And in the nodular patients, the highest maximum significant