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our main speakers for today. Again, as I mentioned at the beginning, are
incredible.

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Fellow team. The hall have a number of projects

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ongoing and had been presenting all around the country in the world. So we get
to hear some of their recent work

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that was presented at the CNS and Kitano, I think you're going to be going
first. Is that correct?

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Yes, sir. All right.

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Let me share my screen.

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All right. Good morning, everyone. So today I'll be presenting on our final
results of procedure and treat

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mental post-op or the CSF leaks. We do ultrasound guided epidural about batch.
And this is a talk that I gave us

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an oral presentation on C and S in Austin. And really was the work of the entire
spine theme here,

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Mayo Clinic, Florida, as well as Dr. Dan and James West.

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I don't have any disclosures relevant to this talk. And as you know,
incidentally,

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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

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to the meaning or seal the report. Their rate of incidental rather me ranges
from four to 16 percent

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depending on the index operation. And if patients develops symptoms of
persistence,

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CSF leak, first-line treatment, bed dressed. Other options include over solving
the wound and placement of a lumbered train.

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And there is the potential need of having to go back to the OR for direct
repair.

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While epidural blood patches are routinely used post anesthesia or LTBI CSF
leaks.

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They are not often use after spine surgery for their alchemy repair. The problem
is that the ultrasound

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is a great technique that allows radiation free and direct real-time
visualization of the meaning of a seal,

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the dura, and the toy needle. By this application in the native spine is often
very limited.

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That's magnified in the bus stop at the spine thanks to the bond work that has
been done by

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removing the bony anatomy and the ligamentous there, which allows a window for
the ultrasound

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and for the need of to be visualized properly. So in our study, we did a
retrospective analysis of

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patient than they were when the USC BPM, Mayo Clinic, Florida from 20092024
syndrome,

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I think to the meaning the seal secondary to spine surgery. We collected
demographic, procedural, and outcome characteristics.

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The primary outcome of our study was ultrasound, EBP success. The final
resolution of

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the initial sync them, their brothers to them in English to clinical attention
such as postural headaches, institutional leak.

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So for our technique, patients that position prone, that ultrasound is used

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to localize the pseudo, meaning the seal and the color Doppler can also be
adopted to determine if there are any active sites

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of leak of aggression. Under ultrasound guidance, 18 gauge toy needle

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is advanced into the syllable, meaning the seal, and the content is aspirated,
but neither is then advanced

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into the epidural space. And about 30 a mile of autologous blood is injected
into early in

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five to ten and aliquots under continuous ultrasound guidance after waiting for
five to ten minutes to

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allow that blood backs to see it. The ultrasound is then used again to confirm
the placement of the patch

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and the color adopt. There can also be used to confirm an absence of CSF egress
if there was previously identified.

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So overall, we add fourth-year patients who underwent a total of six to one USC
bps.

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And you can see that the most frequent index operation was a laminectomy, 24.5%.

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And about 36.7% of these cases where revision surgeries. And also there the

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incident that the relative me was unrecognized during the surgery in about 22%
of cases.

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You can see here that the median time from Sir did the symptom development it
was seven days.

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And the most frequent presentations seen thumbs-up presentation where headaches
in 64% of

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cases and institutional leak in 26.5% of cases. Here, looking at the results of

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the EBP under ultrasound guidance, you can see that 51% of patients experience
resolution

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of their seen them after their first blood batch. And you can see in the medium
volume I separated

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from the meaningless it was 34 and Mao. And also that another 20 percent

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of patients experience resolution or they're seen them after subsequent attempts
of blood patches.

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We're talking about complication. We had about 14 percent complication in our
series.

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Send the most people. One was one infection in patients followed by meningitis.
All seem to patients.

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Get us a couple of illustrative cases. You can see here patients that present
throughout AB fistula.

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And here on the teeth of sagittal MRI you can see a fairly large to them in
English seal.

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After the patient had undergone laminectomy, it's a number variation or the AV
fistula. And then Dipesh, and then when

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they know if they're sound epithelium, but actually the contents of the pseudo,
meaning the cmos aspirate to them but batch placed.

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And then you can see on the post-operative MRI sagittal cut, there was than one
month after the procedure,

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complete resolution or the pseudo meaning Lucille. This is another case of

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a patient that lemon Act. And as you can see here on the CT scan, on the level
of bullet previous fusion construct.

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And there is an IPO density, there have a collection fluid collection. There was
also again identified under

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ultrasound where you can see the star there. And then the color Doppler was used
to identify the active CSF aggression there.

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The toy needle you can see here in white where this big arrow is, it's inserted
the continents

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zooming basileus aspirate as you can see in figure E. And then the blood patch
is placed.

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And this is a post-operative scan, documents resolution or the pseudo meaning
the seal.

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So our study carousel delimitation of all single institution or retrospective
studies therefore fired

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their prospective them with this enter establish that are needed to confirm the
generalized ability of our data.

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But our study is the first and the largest series describing the adoption of us
EBP.

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Impatient percent thing with persistence to the meaning the seal and CSF leak
following spine surgery,

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we've found an overall success rate of over 70 percent with the first attempt
success rate of 50 percent.

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So this suggests that the utilization of us guided EBP in expert Han may allow
for targeted treatment of

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a large portion of symptomatic post-operative sort of meaningless seals. Thank
you. Okay, tunnel

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and it's excellent work. Congratulations. That's a novel treatment for these non
uncommon problems.

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Well, one thing that I realized I never asked Dr. Miller, Dr. Clinton, and
what's the consistency of

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the blood that you're using is the patch and how long is it in-between obtaining
the autologous blood

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and actually injecting it? I don't know about the time between

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when the blood is drawn and Jack this or buy most of them. I believe it may have
been dying

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this at the same time with the procedure, sir. Yeah. But I mean, they they
aspirate

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and immediately give it didn't I was just curious about how thick the blood is.
Maybe a layered I see doctrine Mahasi,

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like Yeah, I do some of these as well. How can we go right away for the blood?

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So it's right from an IV catheter into the epidural space. But what's really
helpful

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is the tissue fibrin glue. So it's like an IRA, you know, human hybrid
components that

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we inject and that solidifies much, much quicker and it's much more firm. So you
know what the blight,

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It's thinner and can get into different crevices while the firearm lose a bit
more firms, you try to get

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both properties and they're right at the week. Excellent. Yeah, thanks. Thanks
Tiana crushing the inlier.

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Did you want to Here hand up there, you want to make a comment? Yeah.

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Yes. Sorry. I can't join on camera because I'm I'm tied up in the hospital.

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But I will like to second-most comments I've done this cup, this case is Dr.
Quint then

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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

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axises identify with the ultrasound machine. And you have fiber

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and who is also been something you that's very helpful for this cases. One
question that I had,

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and it's something that we always worry about is the risk of infection and
meningitis and

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is interesting from the data present. It's too, I believe. Any thoughts stone,

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you're looking at the data and it's anything that we can do to make things
better or reduce that risk score is

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contributed directly to the to the block itself or how their circumstances are

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most patients, they got infections. Thank you. Yes, sir. Excellent question as
he said.

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Oh yeah, we have about two patients and by 4 percent, for our cities, small
cities is difficult to generalize

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if that's really a 4% for the procedure itself. But it was assumed to be array
was

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many jaggedness seem to be related to the procedure, not like a UTI or any other
infections.

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Let's see. We have a question from

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Dr. Vargas about what what about the presence of fibrous tissue after the
procedure?

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I think. Yeah. So hold it down and I have a scar and that sort of thing. Yeah.

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So these are usually done right after the procedure. It's not too long and
that's why it's very difficult to

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do them anatomically guarded. That's why they used facade. The ultrasound really
helps to visualize the anatomy.

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And that's far we didn't have any issues as far as fiber going through a fiber
species. Are the patches.

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Great. Well, thank you so much. Tana. Yeah.

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A couple more points here, Dr. Dean mentioned would emphasize the need to make
sure the patient is a febrile and has

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normal white blood cell count prior to the blood patch. And I know that's that's
part of

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the protocol. And a good point. Some of these patients are immediate post-op
prove.

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They have an immediate postoperative status. So they might have an elevated
white blood cell count just from surgery.

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But yet very, very good point. So I'll relax.

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So excellent workday Taino, and we will go on to the next presentation.
"SPECT-CT as a

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We have Dr. Garcia who's going to be presenting next.

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Can you see this darker folks? Yes. It's advancing by itself.

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Alright. So morning everyone. Today I'm going to be presenting on SPECT CT is a
pretty curved pain generators and patients

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undergoing intra-articular injections for neck and back pain. I think most of
you already know this project.

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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

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Austin at the Commerce Search. And so as you know, low back pain and also neck
pain.

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But there's a lot more literature on low back pain is one of the main leading
causes of disability in general.

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And yet, the identification of painful generators is still difficult, spite of
use of multiple morphological base studies

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including X-ray, CT, MRI. And also compounded by the fact that sometimes
structural abnormalities are found

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on scans have no direct correlation with the actual pain of the patient, which
makes the correct identification of

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the painful generator difficult and therefore, the targeted treatment for that
painful generator

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also difficult and limited. With this in mind, there have been some interest in
functional based tests

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like SPECT to accurately identify those painful generators.

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And more recently, a scan has been a valve which is called hybrid SPECT CT,

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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

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and one of the examples camps. So the idea here was to look at for set joint
injection started

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injections and see whether or not the hypothesis that injections targeted ad
positive sites of uptake

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would do better than injection was targeted for sale without uptake. So to
accomplish this with design,

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the study was single institution retrospective, in which we compared both short
and long-term outcomes

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for patients undergoing a saturated injections for neck and back pain. And given
the large sample size,

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I was able to do a propensity score match to adjust for age, gender, BMI,
hypertension, and multiple target injections and

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injection location did exclude sacroiliac joint injections. Given that they're a
bit

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different and they should not be grouped how the same with cervical, thoracic
and lumbar injections.

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So these were our main outcomes. We looked at immediate positive response,
change in VAS two weeks after injection,

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improvement in VS above 50 and 70 percent after injection and needs for
additional treatment,

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both injection and surgery. Importantly, add mayo. We have people who do call
these patients to

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access the procedure who are not implicated in the research. So they're able to
give us

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an unbiased feedback from the patients with our official report outcomes, which
allowed us to

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really objectify this outcomes. So as you can see, we have a large number of
patients,

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2849 patients that were evaluated with SPECT CT. Within five years out

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of this one as we had three for 340 with the set injections within a 150 days
after SPECT CT.

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Why a 150 days? We had to choose a threshold. There is no specific

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literature on the threshold. We just had to come up with a threshold that would
allow us to look at outcomes that

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were associated with injection, not associated with something else I could have
happened in the interlude.

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So we had a total of a 140 surgical injections, 21 thoracic injections,

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and 207 lumbar injections. Importantly 265. Where uptake targeted injections by
this

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we mean that all the injections with targeted for Sarah, Bob take all of them.
That was our definition

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of uptake target injections and 75 or none uptake targeted injections. So as you
can see here, just an

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example of a SPECT CT and male with in this particular patient or ride L4, L5.

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If I said join having uptake that was targeted by injection, this is actually
one of the cases there was included in the study.

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So here just some demographics and characteristics of the location and
characteristics of the injection.

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As you can see, even though there's nothing that is statistically significant,
they can always compound and have an effect,

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a confounding effect on the variables. Hence, why we did the propensity score
match to adjust for all these variables.

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And what you can see here is that both on a unit variable analysis and the
multivariable analysis,

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we did not find statistically significant differences between not non uptake

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and uptick targeted injections. But when we did look at patients who already had
a failed injection before

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the SPECT CT in which the surgeon or procedures was able to change the target
page

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based on the information of the SPECT CT. Here below, what you can see is that
in those patients we do have a benefit.

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And the benefit was particularly greater if there was any change made on a
target. So that is very

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suggestive that for a particular set of patients. Adequate patient selection,
you do see a benefit with SPECT,

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CT to guide, etc, and injections. So basically our conclusions seem to

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support that pending adequate patient selections, satiety has a benefit

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in guiding facet injections. There are limitations, of course, with our
retrospectives

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seeing institutions study, but we did use a propensity score tonight for
confounding variables. We have a large sample size.

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But of course, a future directions would have to be prospective, multi-site,

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hopefully double-blind clinical trial to accurately discern the impact of SPECT,

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CT and routine clinical practice. And I'll take any questions.

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Excellent Diego, really fabulous work. And I think this is yeah,

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there's so much potential applicability to using imaging biomarkers

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for better delineating patient's pain. In this, even with

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the precision of these specs studies, it shows how challenging it can be

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to figure out pain generators in the spine. And I think this is incredible work
with

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a lot of promise based on what you've seen so far. Could you think, I mean, do
you think they

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should we should be doing this more or less? Or do you think people should have,
have this up front of me?

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How do you recommend we use this based on your knowledge of the technique in our
everyday practice.

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So in a patient with IDC have a benefit where patients in which there were had
already been an attempt at an injection.

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So because my understanding is that's equity is but not necessarily specific.

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So it's difficult to figure out which of those facets are lighting up are the
ones that are actually causing pain.

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So when we have the benefit of having a patient that already had a procedure, it
had failed. We do know which of

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those joints to light it up, but it's not the actual painful generator. So we
can take those out and pursued next ones.

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So I do see FAT City are not as unnecessary first-line for any patient that has
the first procedure.

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But for a recurrent setting injection per patient who has not benefited from a
percent injection,

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I will definitely see benefit there. But of course, I think to actually make a
recommendation would have to have double-blind clinical trials

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so it can make a recommendation. Hopefully coming, Hope we felt

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the end and we'll continue to learn more about these imaging biomarkers, which I
think will be very helpful.

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Dr. Dean makes a great point in the comments as well that we have extremely
high-quality SPECT study.

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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

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senior and very impressed with the quality of the studies. So excellent work.
All right.

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I think we can move on now to our next presentation.

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Dr. Be vesper try though, who is going to be speaking about supramarginal
resection impact on

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overall survival for IDH wild-type glioblastoma. Okay. Perfect. Can you hear me
now?

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Yes. Yes. Thank you. Try today. Let me share screen here.

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All right. Are you seeing my slide? Yes. Perfect. "Supramarginal

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Good morning, everyone. Thank you for attending this lecture today. So I'm going
to present our study that

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started presented in October this year and CNS. And the title of the study
support margin our resection

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impact on overall survival for IDH1, blah, blah. So my according to their cell
density distribution

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on the protection profile, the same month on bottom. So we have now these
contours

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for this lecture. So a bit of background regarding the center of our section on
glioblastoma.

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We know that no long ago they must come on, Sorry, NCA recommendation for

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glioblastoma to perform only a biopsy. And this was not only in the United
States but worldwide,

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but seeing that too tough since we started seeing very important studies from
doctrinal

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across from Dr. McGurk, from Dr. Sinai, from UCSF with Dr. Berger,

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and from China and split this data from updates that of

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these studies favor or perform a more extensive surgical resection

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on patients with glioblastoma. And their results were pretty much homogeneous.

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Identifying that at resections about 78% of a contrast enhancement and T1,

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where we were associated with a significant improvement in

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overall survival in patients with GBS. But furthermore, we see that

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the gross total resection is days, you say, is

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this complete surgical resection or the contrast and husband component of the
tumor.

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And you can see up here. But what about day blur? I'm putting a T2 sequence

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that we have now and for, for a while already that there are infiltrated GPM
cells within the brain tissue

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that most of the time is being taken care of,

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resected because of day. People traded behavior of this,

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of these cells within the brain. That if you were saying that I do can cause a
devastating

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dimensionality of the patient. So we end with other group and may have

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plenty to start looking at the extent of the supramarginal resection, be John,
the margins of

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the contrast enhancement and tumor. And we have seen that regarding this topic,

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that is B has been replaced by results from the from the boot,

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results from external precession beyond the margins in the luxury player them as
we see here,

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very important papers from the MD Anderson, from Hopkins, from Cleveland Clinic,
and from UCSF.

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And not all of them have homogeneous results as we

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found before in the, in the Coursera restriction for the T1 contrast.

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So we're going to give it a shot. And thanks to all of the data

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that we have made a clinic without the high flow of patients we were, we were
able to do

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this study in which we identify more than 800 patients and we selected

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only those patients that were IDH mutants. This is the most aggressive type of

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GBM that has a, a, a, a less overalls Bible in total only selected those
patients.

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That had a grocer urbanization of the contrast enhancement.

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And that they did present before the surgery with some degree of pre-operative
pillar.

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So in total we including 101 patients, we we perform all photometric analysis

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on all the sequences in the, in the contract and constant in DNA cross is part
and in differ for all the patients.

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And we did find a univariate, multivariate analysis that the increase

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in SMR as a continuous viral for the first time we showed that is that is
statistically

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significant for an increase and improve overall survival in our patient
population.

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And furthermore, when we perform a nutritional analysis, we found that those
restrictions

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about 20 percent and 60 percent of words that were related with a significant
increase in number algebra,

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Bible. So to summarize our findings, we did this illustration that

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shows that the green part and they were in proportion, or the percentage is from

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above 20 and 60 percent were related. We can improve plurals for Bible. And we
didn't find a significant benefiting

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those restrictions about 60 percent, that is the red portion of the figure here.

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So now we know that increasingly summarize beneficial for, for, for,

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for finding profiles for wavelength in our patients would IDH type wild-type
GPM.

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But we know that there's a falsely high variability in their ideological
presentation of

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our group in general and GBM, but also in ideation. So we partner with

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the mathematical neural colleague laboratory. I may have been the Arizona with
Dr. Christina. So insulin to try to

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further personalize they they they are to try to be more specific with

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using a specific patient characteristics from their ideological data.

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And we can see that follow in our hypotheses at the center of the, of the, of
the, of the lesion.

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They wonder is in close proximity with the contrast enhancement our acid greater
or more burden.

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So our concentration over there. And once you're going to the periphery, you see
that the low density,

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the density of these tumor cells is, is slower. So this is the formula that we

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use in our patient population. In summary, for dangerous or down, you can see
that in the one with contrast,

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devolving was approximately one is spherical shape. And we saw that they, these
hard,

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this portion has a greater cell density compared to the cell density in the T2
flair.

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So with these results, we classify our patient population

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in three groups that were nodular, moderately diffuse, and highly diffuse
according to their,

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to their, to their, to their tumor cell density and distribution profile.

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So this is a representation from some of the patients that were

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selected and classify and including this. Groups, you can see here and
binocular, they have more contrast enhancement

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than blur and seeing them well it'll diffuse. You see that there is a, some more
player in the patient's surrounding

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a tip as well lenient on T1. I think the highly perfused you see that

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the variance is greater than the other groups. So producing the univariate
analyses,

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we saw that the US seem statistically significant only for moderate

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and diffuse and highly diffuse. Okay. But it wasn't significant or not there.

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This is in univariate. And the same results were obtained for a multi-barrier
now that we see was

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statistically significant for monetarily and how they diffuse or another by when
we perform a treasure analysis,

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we saw that the nodular there is actually a benefit only in

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resections from 10 to 10 percent. And this is kind of

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logical because the Northern learned there is not much clear as we showed you in
the in the MRI before.

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So there's no much benefit in extending the intersection beyond the

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20% of the contrast enhancement. And they know the red group in their motherly
diffuse,

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we found benefits from all the way up to 50%. You can see here in the highly
diffused,

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we only saw benefits beyond 30 percent, all the way up to 90 and 90 plus
percent.

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So this is very important because now we can, based on this study,

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at least in these results, we see that there is a very important benefit in the,

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in the supramarginal resection of these patients. And of course, based on

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their biological characteristics before the surgery, the surgeons can decide

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how much the patient can need a, need a resection, and extent of resection base
and decent.

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For example, in these highly tumors, we found that this is the maximum SAMR
really

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correlated with Albert DeSalvo. So bible, you can see that the patients that had
every section

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above 90 percent with they once had a better overall should, why would that be
one that

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had less than 90 percent? And these patient populations had a greater survival
of, let's see.

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If I remember correctly, almost nine months greater than the patient that had a
resection or with less than 90 percent.

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For them modally diffuse, the highest SAMR percentage was 50.

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And these patient presented with a benefit. I'm opening up an additional seven
months.

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And in the nodal or patients, the highest maximum significantly co-related would
be shallower

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as Weber was 20 percent. And these patients had a, a, an additional overall
survival or 10 months.

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So to summarize, for all our findings, they might go it's an iron or elsewhere
Bible in ideas,

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whilst the CAPM is influenced by the degree of tumor invasiveness, a result
showed an increase

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in SMR is associated with they suddenly become beneficial overall survivor in
moderate and highlight the idea that GBM,

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I did that in traditional analysis 90, 50, and 20 percent work on the upper
limit,

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That's MR. percentage associated with They'd been a pizza overall survival and
kind of diffuse mode earlier refused.

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I know that are timeless respectively. So that's all that we have for today.

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Thank you very much for attending any questions.

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Great work. Really interesting stuff. And I don't really do tumor work anymore.

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But one question I had from my perspective is this all seems to make really good
sense to me given the nature

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of gliomas and how invasive they are into the brain. If you're able to resect
the rim around the tumor,

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you'd have better survival. I'm just curious. Do you think there is any kind of

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selection bias as to who does better based on just where the tumor is. Because
if you're next to an eloquent area,

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of course he can't do that. Or how did how do you mitigate that isn't does that
mean more awake

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surgery for these tumors, which I know we do a lot of here, but maybe other
places don't do so much.

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So what do you, what do you recommend about that? Yes, of course, we will

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talk about beta for dangerous of time. We've already included here, but yeah,
tumor occasional was so associated with it.

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The overall survival of patients and of course, obey of the tumor,

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they were located you plug child areas are where we had a deeper location or
proximity with the actual ventricles

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had a a worst prognosis. And and of course, I mean, it is easier to add

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to a greater restrictions on, on, on those tumors that are located a non
elephant

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parts of the brain, of course. So, but yeah, but to mitigate those challenges,

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we recommend that, you know, most of the cases that can be should be

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performed with an awake brain surgery, you know, in, in correlation with

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narrow physiological monitoring and all these two to try to prevent any further
functional.

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Now, BAM machine, the patient has been proven also.

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And he doesn't matter how great the restriction that he said

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accomplish if they don't cost that much in the functionality of the patient. All
these benefits will be overcome by day.

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They decrease overall survival and the quality of life of the patient. If they
have a a a baby up their surgery.

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Yeah. I mean, that's a really good point because that data is out there with
the, with the neurologic deficit there,

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any survival benefit goes away. Watching the tight rope between

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resection and maintaining neurologic function. And very interesting, great work.

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Well, congratulations to all three of you. This is truly amazing as I put in the
chat, I'm, I'm,

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I'm frequently blown away by what our fellows are doing, how hard you guys all
work in

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all three shields and your dedication is truly incredible. So it's

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a real pleasure to work with you guys. And I made them feel very fortunate to to
have that opportunity.

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So there are not any other questions. I think we're 759,

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we're right on time and hope everyone has a great week. Thank you for joining us
and see you soon