our main speakers for today. Again, as I mentioned at the beginning, are incredible.
Fellow team. The hall have a number of projects
ongoing and had been presenting all around the country in the world. So we get to hear some of their recent work
that was presented at the CNS and Kitano, I think you're going to be going first. Is that correct?
Yes, sir. All right.
Let me share my screen.
All right. Good morning, everyone. So today I'll be presenting on our final results of procedure and treat
mental post-op or the CSF leaks. We do ultrasound guided epidural about batch. And this is a talk that I gave us
an oral presentation on C and S in Austin. And really was the work of the entire spine theme here,
Mayo Clinic, Florida, as well as Dr. Dan and James West.
I don't have any disclosures relevant to this talk. And as you know, incidentally,
the rod them it is a very well-known complication of spine surgery. And if left untreated, it can lead to a persistence CSF leak course
to the meaning or seal the report. Their rate of incidental rather me ranges from four to 16 percent
depending on the index operation. And if patients develops symptoms of persistence,
CSF leak, first-line treatment, bed dressed. Other options include over solving the wound and placement of a lumbered train.
And there is the potential need of having to go back to the OR for direct repair.
While epidural blood patches are routinely used post anesthesia or LTBI CSF leaks.
They are not often use after spine surgery for their alchemy repair. The problem is that the ultrasound
is a great technique that allows radiation free and direct real-time visualization of the meaning of a seal,
the dura, and the toy needle. By this application in the native spine is often very limited.
That's magnified in the bus stop at the spine thanks to the bond work that has been done by
removing the bony anatomy and the ligamentous there, which allows a window for the ultrasound
and for the need of to be visualized properly. So in our study, we did a retrospective analysis of
patient than they were when the USC BPM, Mayo Clinic, Florida from 20092024 syndrome,
I think to the meaning the seal secondary to spine surgery. We collected demographic, procedural, and outcome characteristics.
The primary outcome of our study was ultrasound, EBP success. The final resolution of
the initial sync them, their brothers to them in English to clinical attention such as postural headaches, institutional leak.
So for our technique, patients that position prone, that ultrasound is used
to localize the pseudo, meaning the seal and the color Doppler can also be adopted to determine if there are any active sites
of leak of aggression. Under ultrasound guidance, 18 gauge toy needle
is advanced into the syllable, meaning the seal, and the content is aspirated, but neither is then advanced
into the epidural space. And about 30 a mile of autologous blood is injected into early in
five to ten and aliquots under continuous ultrasound guidance after waiting for five to ten minutes to
allow that blood backs to see it. The ultrasound is then used again to confirm the placement of the patch
and the color adopt. There can also be used to confirm an absence of CSF egress if there was previously identified.
So overall, we add fourth-year patients who underwent a total of six to one USC bps.
And you can see that the most frequent index operation was a laminectomy, 24.5%.
And about 36.7% of these cases where revision surgeries. And also there the
incident that the relative me was unrecognized during the surgery in about 22% of cases.
You can see here that the median time from Sir did the symptom development it was seven days.
And the most frequent presentations seen thumbs-up presentation where headaches in 64% of
cases and institutional leak in 26.5% of cases. Here, looking at the results of
the EBP under ultrasound guidance, you can see that 51% of patients experience resolution
of their seen them after their first blood batch. And you can see in the medium volume I separated
from the meaningless it was 34 and Mao. And also that another 20 percent
of patients experience resolution or they're seen them after subsequent attempts of blood patches.
We're talking about complication. We had about 14 percent complication in our series.
Send the most people. One was one infection in patients followed by meningitis. All seem to patients.
Get us a couple of illustrative cases. You can see here patients that present throughout AB fistula.
And here on the teeth of sagittal MRI you can see a fairly large to them in English seal.
After the patient had undergone laminectomy, it's a number variation or the AV fistula. And then Dipesh, and then when
they know if they're sound epithelium, but actually the contents of the pseudo, meaning the cmos aspirate to them but batch placed.
And then you can see on the post-operative MRI sagittal cut, there was than one month after the procedure,
complete resolution or the pseudo meaning Lucille. This is another case of
a patient that lemon Act. And as you can see here on the CT scan, on the level of bullet previous fusion construct.
And there is an IPO density, there have a collection fluid collection. There was also again identified under
ultrasound where you can see the star there. And then the color Doppler was used to identify the active CSF aggression there.
The toy needle you can see here in white where this big arrow is, it's inserted the continents
zooming basileus aspirate as you can see in figure E. And then the blood patch is placed.
And this is a post-operative scan, documents resolution or the pseudo meaning the seal.
So our study carousel delimitation of all single institution or retrospective studies therefore fired
their prospective them with this enter establish that are needed to confirm the generalized ability of our data.
But our study is the first and the largest series describing the adoption of us EBP.
Impatient percent thing with persistence to the meaning the seal and CSF leak following spine surgery,
we've found an overall success rate of over 70 percent with the first attempt success rate of 50 percent.
So this suggests that the utilization of us guided EBP in expert Han may allow for targeted treatment of
a large portion of symptomatic post-operative sort of meaningless seals. Thank you. Okay, tunnel
and it's excellent work. Congratulations. That's a novel treatment for these non uncommon problems.
Well, one thing that I realized I never asked Dr. Miller, Dr. Clinton, and what's the consistency of
the blood that you're using is the patch and how long is it in-between obtaining the autologous blood
and actually injecting it? I don't know about the time between
when the blood is drawn and Jack this or buy most of them. I believe it may have been dying
this at the same time with the procedure, sir. Yeah. But I mean, they they aspirate
and immediately give it didn't I was just curious about how thick the blood is. Maybe a layered I see doctrine Mahasi,
like Yeah, I do some of these as well. How can we go right away for the blood?
So it's right from an IV catheter into the epidural space. But what's really helpful
is the tissue fibrin glue. So it's like an IRA, you know, human hybrid components that
we inject and that solidifies much, much quicker and it's much more firm. So you know what the blight,
It's thinner and can get into different crevices while the firearm lose a bit more firms, you try to get
both properties and they're right at the week. Excellent. Yeah, thanks. Thanks Tiana crushing the inlier.
Did you want to Here hand up there, you want to make a comment? Yeah.
Yes. Sorry. I can't join on camera because I'm I'm tied up in the hospital.
But I will like to second-most comments I've done this cup, this case is Dr. Quint then
and a lot of times what we do is we place an arterial lines so that way we can reliably draw blood right away as soon as
axises identify with the ultrasound machine. And you have fiber
and who is also been something you that's very helpful for this cases. One question that I had,
and it's something that we always worry about is the risk of infection and meningitis and
is interesting from the data present. It's too, I believe. Any thoughts stone,
you're looking at the data and it's anything that we can do to make things better or reduce that risk score is
contributed directly to the to the block itself or how their circumstances are
most patients, they got infections. Thank you. Yes, sir. Excellent question as he said.
Oh yeah, we have about two patients and by 4 percent, for our cities, small cities is difficult to generalize
if that's really a 4% for the procedure itself. But it was assumed to be array was
many jaggedness seem to be related to the procedure, not like a UTI or any other infections.
Let's see. We have a question from
Dr. Vargas about what what about the presence of fibrous tissue after the procedure?
I think. Yeah. So hold it down and I have a scar and that sort of thing. Yeah.
So these are usually done right after the procedure. It's not too long and that's why it's very difficult to
do them anatomically guarded. That's why they used facade. The ultrasound really helps to visualize the anatomy.
And that's far we didn't have any issues as far as fiber going through a fiber species. Are the patches.
Great. Well, thank you so much. Tana. Yeah.
A couple more points here, Dr. Dean mentioned would emphasize the need to make sure the patient is a febrile and has
normal white blood cell count prior to the blood patch. And I know that's that's part of
the protocol. And a good point. Some of these patients are immediate post-op prove.
They have an immediate postoperative status. So they might have an elevated white blood cell count just from surgery.
But yet very, very good point. So I'll relax.
So excellent workday Taino, and we will go on to the next presentation. "SPECT-CT as a
We have Dr. Garcia who's going to be presenting next.
Can you see this darker folks? Yes. It's advancing by itself.
Alright. So morning everyone. Today I'm going to be presenting on SPECT CT is a pretty curved pain generators and patients
undergoing intra-articular injections for neck and back pain. I think most of you already know this project.
It's a project that we did with the spine group and on the particular mentorship up to our body Yammer. And we presented it at
Austin at the Commerce Search. And so as you know, low back pain and also neck pain.
But there's a lot more literature on low back pain is one of the main leading causes of disability in general.
And yet, the identification of painful generators is still difficult, spite of use of multiple morphological base studies
including X-ray, CT, MRI. And also compounded by the fact that sometimes structural abnormalities are found
on scans have no direct correlation with the actual pain of the patient, which makes the correct identification of
the painful generator difficult and therefore, the targeted treatment for that painful generator
also difficult and limited. With this in mind, there have been some interest in functional based tests
like SPECT to accurately identify those painful generators.
And more recently, a scan has been a valve which is called hybrid SPECT CT,
which at Mayo we have been fortunate, have available for a number of years and we're good quality as I'm going to show
and one of the examples camps. So the idea here was to look at for set joint injection started
injections and see whether or not the hypothesis that injections targeted ad positive sites of uptake
would do better than injection was targeted for sale without uptake. So to accomplish this with design,
the study was single institution retrospective, in which we compared both short and long-term outcomes
for patients undergoing a saturated injections for neck and back pain. And given the large sample size,
I was able to do a propensity score match to adjust for age, gender, BMI, hypertension, and multiple target injections and
injection location did exclude sacroiliac joint injections. Given that they're a bit
different and they should not be grouped how the same with cervical, thoracic and lumbar injections.
So these were our main outcomes. We looked at immediate positive response, change in VAS two weeks after injection,
improvement in VS above 50 and 70 percent after injection and needs for additional treatment,
both injection and surgery. Importantly, add mayo. We have people who do call these patients to
access the procedure who are not implicated in the research. So they're able to give us
an unbiased feedback from the patients with our official report outcomes, which allowed us to
really objectify this outcomes. So as you can see, we have a large number of patients,
2849 patients that were evaluated with SPECT CT. Within five years out
of this one as we had three for 340 with the set injections within a 150 days after SPECT CT.
Why a 150 days? We had to choose a threshold. There is no specific
literature on the threshold. We just had to come up with a threshold that would allow us to look at outcomes that
were associated with injection, not associated with something else I could have happened in the interlude.
So we had a total of a 140 surgical injections, 21 thoracic injections,
and 207 lumbar injections. Importantly 265. Where uptake targeted injections by this
we mean that all the injections with targeted for Sarah, Bob take all of them. That was our definition
of uptake target injections and 75 or none uptake targeted injections. So as you can see here, just an
example of a SPECT CT and male with in this particular patient or ride L4, L5.
If I said join having uptake that was targeted by injection, this is actually one of the cases there was included in the study.
So here just some demographics and characteristics of the location and characteristics of the injection.
As you can see, even though there's nothing that is statistically significant, they can always compound and have an effect,
a confounding effect on the variables. Hence, why we did the propensity score match to adjust for all these variables.
And what you can see here is that both on a unit variable analysis and the multivariable analysis,
we did not find statistically significant differences between not non uptake
and uptick targeted injections. But when we did look at patients who already had a failed injection before
the SPECT CT in which the surgeon or procedures was able to change the target page
based on the information of the SPECT CT. Here below, what you can see is that in those patients we do have a benefit.
And the benefit was particularly greater if there was any change made on a target. So that is very
suggestive that for a particular set of patients. Adequate patient selection, you do see a benefit with SPECT,
CT to guide, etc, and injections. So basically our conclusions seem to
support that pending adequate patient selections, satiety has a benefit
in guiding facet injections. There are limitations, of course, with our retrospectives
seeing institutions study, but we did use a propensity score tonight for confounding variables. We have a large sample size.
But of course, a future directions would have to be prospective, multi-site,
hopefully double-blind clinical trial to accurately discern the impact of SPECT,
CT and routine clinical practice. And I'll take any questions.
Excellent Diego, really fabulous work. And I think this is yeah,
there's so much potential applicability to using imaging biomarkers
for better delineating patient's pain. In this, even with
the precision of these specs studies, it shows how challenging it can be
to figure out pain generators in the spine. And I think this is incredible work with
a lot of promise based on what you've seen so far. Could you think, I mean, do you think they
should we should be doing this more or less? Or do you think people should have, have this up front of me?
How do you recommend we use this based on your knowledge of the technique in our everyday practice.
So in a patient with IDC have a benefit where patients in which there were had already been an attempt at an injection.
So because my understanding is that's equity is but not necessarily specific.
So it's difficult to figure out which of those facets are lighting up are the ones that are actually causing pain.
So when we have the benefit of having a patient that already had a procedure, it had failed. We do know which of
those joints to light it up, but it's not the actual painful generator. So we can take those out and pursued next ones.
So I do see FAT City are not as unnecessary first-line for any patient that has the first procedure.
But for a recurrent setting injection per patient who has not benefited from a percent injection,
I will definitely see benefit there. But of course, I think to actually make a recommendation would have to have double-blind clinical trials
so it can make a recommendation. Hopefully coming, Hope we felt
the end and we'll continue to learn more about these imaging biomarkers, which I think will be very helpful.
Dr. Dean makes a great point in the comments as well that we have extremely high-quality SPECT study.
Is it Mayo which I completely agree at UF, we didn't do this at all. So this was, this was something novel to me
senior and very impressed with the quality of the studies. So excellent work. All right.
I think we can move on now to our next presentation.
Dr. Be vesper try though, who is going to be speaking about supramarginal resection impact on
overall survival for IDH wild-type glioblastoma. Okay. Perfect. Can you hear me now?
Yes. Yes. Thank you. Try today. Let me share screen here.
All right. Are you seeing my slide? Yes. Perfect. "Supramarginal
Good morning, everyone. Thank you for attending this lecture today. So I'm going to present our study that
started presented in October this year and CNS. And the title of the study support margin our resection
impact on overall survival for IDH1, blah, blah. So my according to their cell density distribution
on the protection profile, the same month on bottom. So we have now these contours
for this lecture. So a bit of background regarding the center of our section on glioblastoma.
We know that no long ago they must come on, Sorry, NCA recommendation for
glioblastoma to perform only a biopsy. And this was not only in the United States but worldwide,
but seeing that too tough since we started seeing very important studies from doctrinal
across from Dr. McGurk, from Dr. Sinai, from UCSF with Dr. Berger,
and from China and split this data from updates that of
these studies favor or perform a more extensive surgical resection
on patients with glioblastoma. And their results were pretty much homogeneous.
Identifying that at resections about 78% of a contrast enhancement and T1,
where we were associated with a significant improvement in
overall survival in patients with GBS. But furthermore, we see that
the gross total resection is days, you say, is
this complete surgical resection or the contrast and husband component of the tumor.
And you can see up here. But what about day blur? I'm putting a T2 sequence
that we have now and for, for a while already that there are infiltrated GPM cells within the brain tissue
that most of the time is being taken care of,
resected because of day. People traded behavior of this,
of these cells within the brain. That if you were saying that I do can cause a devastating
dimensionality of the patient. So we end with other group and may have
plenty to start looking at the extent of the supramarginal resection, be John, the margins of
the contrast enhancement and tumor. And we have seen that regarding this topic,
that is B has been replaced by results from the from the boot,
results from external precession beyond the margins in the luxury player them as we see here,
very important papers from the MD Anderson, from Hopkins, from Cleveland Clinic, and from UCSF.
And not all of them have homogeneous results as we
found before in the, in the Coursera restriction for the T1 contrast.
So we're going to give it a shot. And thanks to all of the data
that we have made a clinic without the high flow of patients we were, we were able to do
this study in which we identify more than 800 patients and we selected
only those patients that were IDH mutants. This is the most aggressive type of
GBM that has a, a, a, a less overalls Bible in total only selected those patients.
That had a grocer urbanization of the contrast enhancement.
And that they did present before the surgery with some degree of pre-operative pillar.
So in total we including 101 patients, we we perform all photometric analysis
on all the sequences in the, in the contract and constant in DNA cross is part and in differ for all the patients.
And we did find a univariate, multivariate analysis that the increase
in SMR as a continuous viral for the first time we showed that is that is statistically
significant for an increase and improve overall survival in our patient population.
And furthermore, when we perform a nutritional analysis, we found that those restrictions
about 20 percent and 60 percent of words that were related with a significant increase in number algebra,
Bible. So to summarize our findings, we did this illustration that
shows that the green part and they were in proportion, or the percentage is from
above 20 and 60 percent were related. We can improve plurals for Bible. And we didn't find a significant benefiting
those restrictions about 60 percent, that is the red portion of the figure here.
So now we know that increasingly summarize beneficial for, for, for,
for finding profiles for wavelength in our patients would IDH type wild-type GPM.
But we know that there's a falsely high variability in their ideological presentation of
our group in general and GBM, but also in ideation. So we partner with
the mathematical neural colleague laboratory. I may have been the Arizona with Dr. Christina. So insulin to try to
further personalize they they they are to try to be more specific with
using a specific patient characteristics from their ideological data.
And we can see that follow in our hypotheses at the center of the, of the, of the, of the lesion.
They wonder is in close proximity with the contrast enhancement our acid greater or more burden.
So our concentration over there. And once you're going to the periphery, you see that the low density,
the density of these tumor cells is, is slower. So this is the formula that we
use in our patient population. In summary, for dangerous or down, you can see that in the one with contrast,
devolving was approximately one is spherical shape. And we saw that they, these hard,
this portion has a greater cell density compared to the cell density in the T2 flair.
So with these results, we classify our patient population
in three groups that were nodular, moderately diffuse, and highly diffuse according to their,
to their, to their, to their tumor cell density and distribution profile.
So this is a representation from some of the patients that were
selected and classify and including this. Groups, you can see here and binocular, they have more contrast enhancement
than blur and seeing them well it'll diffuse. You see that there is a, some more player in the patient's surrounding
a tip as well lenient on T1. I think the highly perfused you see that
the variance is greater than the other groups. So producing the univariate analyses,
we saw that the US seem statistically significant only for moderate
and diffuse and highly diffuse. Okay. But it wasn't significant or not there.
This is in univariate. And the same results were obtained for a multi-barrier now that we see was
statistically significant for monetarily and how they diffuse or another by when we perform a treasure analysis,
we saw that the nodular there is actually a benefit only in
resections from 10 to 10 percent. And this is kind of
logical because the Northern learned there is not much clear as we showed you in the in the MRI before.
So there's no much benefit in extending the intersection beyond the
20% of the contrast enhancement. And they know the red group in their motherly diffuse,
we found benefits from all the way up to 50%. You can see here in the highly diffused,
we only saw benefits beyond 30 percent, all the way up to 90 and 90 plus percent.
So this is very important because now we can, based on this study,
at least in these results, we see that there is a very important benefit in the,
in the supramarginal resection of these patients. And of course, based on
their biological characteristics before the surgery, the surgeons can decide
how much the patient can need a, need a resection, and extent of resection base and decent.
For example, in these highly tumors, we found that this is the maximum SAMR really
correlated with Albert DeSalvo. So bible, you can see that the patients that had every section
above 90 percent with they once had a better overall should, why would that be one that
had less than 90 percent? And these patient populations had a greater survival of, let's see.
If I remember correctly, almost nine months greater than the patient that had a resection or with less than 90 percent.
For them modally diffuse, the highest SAMR percentage was 50.
And these patient presented with a benefit. I'm opening up an additional seven months.
And in the nodal or patients, the highest maximum significantly co-related would be shallower
as Weber was 20 percent. And these patients had a, a, an additional overall survival or 10 months.
So to summarize, for all our findings, they might go it's an iron or elsewhere Bible in ideas,
whilst the CAPM is influenced by the degree of tumor invasiveness, a result showed an increase
in SMR is associated with they suddenly become beneficial overall survivor in moderate and highlight the idea that GBM,
I did that in traditional analysis 90, 50, and 20 percent work on the upper limit,
That's MR. percentage associated with They'd been a pizza overall survival and kind of diffuse mode earlier refused.
I know that are timeless respectively. So that's all that we have for today.
Thank you very much for attending any questions.
Great work. Really interesting stuff. And I don't really do tumor work anymore.
But one question I had from my perspective is this all seems to make really good sense to me given the nature
of gliomas and how invasive they are into the brain. If you're able to resect the rim around the tumor,
you'd have better survival. I'm just curious. Do you think there is any kind of
selection bias as to who does better based on just where the tumor is. Because if you're next to an eloquent area,
of course he can't do that. Or how did how do you mitigate that isn't does that mean more awake
surgery for these tumors, which I know we do a lot of here, but maybe other places don't do so much.
So what do you, what do you recommend about that? Yes, of course, we will
talk about beta for dangerous of time. We've already included here, but yeah, tumor occasional was so associated with it.
The overall survival of patients and of course, obey of the tumor,
they were located you plug child areas are where we had a deeper location or proximity with the actual ventricles
had a a worst prognosis. And and of course, I mean, it is easier to add
to a greater restrictions on, on, on those tumors that are located a non elephant
parts of the brain, of course. So, but yeah, but to mitigate those challenges,
we recommend that, you know, most of the cases that can be should be
performed with an awake brain surgery, you know, in, in correlation with
narrow physiological monitoring and all these two to try to prevent any further functional.
Now, BAM machine, the patient has been proven also.
And he doesn't matter how great the restriction that he said
accomplish if they don't cost that much in the functionality of the patient. All these benefits will be overcome by day.
They decrease overall survival and the quality of life of the patient. If they have a a a baby up their surgery.
Yeah. I mean, that's a really good point because that data is out there with the, with the neurologic deficit there,
any survival benefit goes away. Watching the tight rope between
resection and maintaining neurologic function. And very interesting, great work.
Well, congratulations to all three of you. This is truly amazing as I put in the chat, I'm, I'm,
I'm frequently blown away by what our fellows are doing, how hard you guys all work in
all three shields and your dedication is truly incredible. So it's
a real pleasure to work with you guys. And I made them feel very fortunate to to have that opportunity.
So there are not any other questions. I think we're 759,
we're right on time and hope everyone has a great week. Thank you for joining us and see you soon