with We are pleased to present you with the latest Newsletter of the Middle East Spine Society.

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1 We are pleased to present you with the latest Newsletter of the Middle East Spine Society. In this issue, Dr. Eko Agus Subagio conducts a Q&A with our Next President, Prof. Mohamed Mohi Eldin. The past OPLL Webinar expands substantially in this issue. Prof. Onur Yaman & Dr. Goktug Akyoldaş provides a focused review of several journals on cervical spine sagittal balance in the journal club section. In addition, we also present a brief report of Spinal Deformity Course last september. Hope everyone thoroughly enjoys this issue and see you on very upcoming events! Prof. Mohamed Mohi Eldin, MD, PhD Prof. mmohi63@yahoo.com Mohamed Mohi Eldin, m Eko Eko Agus Agus Subagio, MD, MD, PhD PhD easnsurg@yahoo.com with President Elect of the Middle East Spine Society Interviewed by Eko A. Subagio, MD, PhD Regarding your upcoming assignment as President of the Middle East Spine Society, we are all aware that today, the world of neurosurgery, especially spine, is marked by a number of exciting changes and daunting challenges. What would you say about this? Spine surgery was practiced for decades. Minimally invasive spine surgery has been available for several years, but the trend has just begun picking up steam across the world. Many surgeons who learned traditional open surgery are content with those procedures. Continued on page 2

2 2 Continued from page 1 exist today. Do you think there is greater potential for the academic and political integration of spine organizations? However, now more spine fellows are seeking to learn minimally invasive (MI) techniques and begin incorporating them into their practices at a faster rate than ever before. Moreover, Complex procedures are now minimally invasive. More spinal surgeries and fusions are more commonly done on Outpatient basis. Here comes the first big challenge, namely, the learning curve and the ability to choose between interventions and MI surgical procedures. Knowing the technique s tips & tricks is important, but the most important is to know the proper indication for each technique. Regeneration which is now becoming popular in several neurosurgical organizations, especially spine, is a resounding success in bringing together representatives from all backgrounds and maybe even political interests that Moving forward with motion preservation, surgeons and scientists have set their sights on biological solutions and disc regeneration. Early technologies are still in the beginning stages and clinical trials, but this area shows the most promise in combating some of the highest pain and cost generators in the world. Disc regeneration seeks to bring the cushion of the spine back to its normal state. These techniques are being researched and there have been some attempts at performing them, but we do not have any solid clinical evidence that will promote the idea we should change the way we treat spinal surgery now. Biologics has permeated the market with bone morphogenic proteins and other similar synthetic fusion materials. Device companies are working on creating a material that allows bone graft substitutes to achieve fusion without harvesting bone from the patient's autogenous bone. These data clarifies the necessity to incorporate both the academic and political aspects into spine organizations to help surgeons to do a safe and Continued on page 3

3 Continued from page 2 3 successful up-to-date spine practice. What technical aspects of spine surgery do you think will have the greatest impact over the next 5 to 10 years? Novel technologies actually are developing to help the surgeon to perform a most accurate, safe, and adequately planned surgery and to reduce the exposure to ionizing radiations. Instead, new techniques are developing as an alternative to standard surgical approaches with specific surgical indications, with the aim of reducing tissue damage, length of hospitalization, and postoperative pain, and of promoting a faster functional restoration. New trends in spinal surgery are going towards a customization of the implants, tailored to the single patient, and towards minimally invasive, percutaneous, and endoscopic surgery. Unfortunately, behind every new technology and technique there is a constant pressure of the companies. Clearly, in light of this, any of them can be validated only by experience, follow-up, and an accurate risk-benefit ratio. Computer navigation could have a place going forward. Computer assistance and robotic guidance for spine have been a contentious issue for the past few years; the equipment is expensive and surgeons question whether it actually improves the procedure enough to warrant that cost. However, there is a market for this technology and future iterations could make an impact on spine care. Lastly, the trend is going into more day case surgeries than the old inpatient admissions. More indications are included with more refinements of techniques and even anesthesia if needed. You have been a prominent figure in the generation and propagation of clinical practice guidelines in spine surgery. What do you imagine the future holds for the intersection of evidence-based medicine, payer policy challenges and medicolegal issues for spine surgery in the next 10 years or so? Evidence-based medicine helps health systems achieve gains on triple aims at once: care, health, and cost. The most important reason for the interest in evidence-based medicine is that it works. Many data show if health systems diligently use the best clinical evidence and expertise, and ensure treatments are consistent with patient values, they will realize better outcomes in every way. Payers, employers, and patients are all driving the need for the healthcare industry to show transparency, accountability, and value (e.g., high quality and safe care at the lowest possible cost). Practicing evidence-based healthcare can help the Continued on page 4

4 Continued from page 3 4 industry achieve these goals. It should be a win-win process to everyone. You have had a unique perspective as an Egyptian neurosurgeon who will lead this society. Are there ways we can better integrate both the educational and administrative aspects of neurosurgery across all of Middle East? Professor Mehmet Zileli, the godfather of the society is leading the whole society into that direction. Prof. Abdel Hafiz Shehab, and Prof. Salman Sharif are working in the same direction. We are establishing integrative and interrogative spine activities spreading the right and correct aspects of spine practice. Nothing can stop this ongoing process of continuous education through more meetings, discussions, case solving, workshops and web-based activities. During your term as President Elect, you are well known for your equity during difficult situations. How do you personally achieve balance as a spine surgeon with increasing clinical, academic, administrative and personal demands? As the landscape of modern spine surgery changes, with increased focus on work life balance combined with increasing clinical, administrative, and managerial demands of academic spine surgeons, the need for outstanding mentors in the field of spine surgery continues to rise. The ways in which individual mentors and mentees ensure the success of their own mentoring relationships, are many. To be a mentor, this is what I am trying to do over the last 10 years. The impact of mentoring on academic spine surgery at an institutional, national, and international level is important and should be continuously evaluated to ensure the ongoing survival and success of our specialty. What advice would you give to young spine surgeons who aspire to become involved in the society and contribute to our organization? To make it as a spine surgeon, you must have a true passion for this great field of medicine. However, it is not enough to be good at it. You must love it. Patients will pick up the spine surgeon who cares. You are going to face challenges. Your passion for the field and a sincere dedication to helping patients must be your driving force. At least one mentor should show you a glimpse into what this field is really like and how passion drives clinical decisions. Mentors show that if you set your mind to it, anything is possible. In addition, every mistake is a lesson learned. Mentors can show you all Continued on page 5

5 5 the ways that spine surgery is truly an art. You may have two patients who present with the identical symptoms, but their correction may require you to perform different techniques in order to achieve the best outcome. There is no doubt that all of us in the society and beyond are grateful for your service and leadership. Congratulations on your achievement as President Elect and thank you for your ongoing commitment to our society. Thank you so much. I am much obliged. 5 Prof. Onur Yaman & Dr. Goktug Akyoldaş In the last webinar that run by Dr. Mehmet ZILELI, Dr. Sandeep VAISHYA discussed updated and detailed knowledge about Surgery for Cervical OPLL on September 24, The highlights of the webinar as follows: OPLL is ossification of the posterior longitudinal ligament and first described in Incidence of the OPLL is higher in Asian population. Male/Female ratio is 2/1. OPLL can be associated with diffuse idiopathic skeletal hyperostosis (DISH). Pathogenesis is unknown. However, type II Diabetes is a risk factor. OPLL is known as a progressive disease. Patients can present with various complaints such as myelopathy signs, gait problems, spasticity, bowel and bladder complaints. In particular, spinal cord injury with minor cervical traumas can be seen. Hirabayashi classification is used for morphological assessment. Computerized tomography (CT) scan is a gold standard for evaluation. Magnetic resonance imaging (MRI) is crucial for evaluating of the neuronal structures. Conservative treatment should be applied to asymptomatic patients. Otherwise, patients with symptomatic myelopathy should be operated by anterior, posterior or combine procedures. Patient s effective lordosis, K-Line measurements, occupancy ratio calculations can aid decision-making. Generally, three or fewer levels OPLL can be treated with anterior approach. Otherwise, more than three levels OPLL can be treated with posterior or combine approaches. Most common complications are neuronal structure damages such as cord injury or C5 palsy in per-operative course and, hematoma, CSF leakage and instability in post-operative course. Continued on page 6

6 6 Prof. Onur Yaman & Dr. Goktug Akyoldaş In the modern era of spine surgery, it is unequivocally crucial for surgeons to have simple, reliable and reproducible parameters to analyze the cervical and global spine, predict evolution and outcome, and plan surgery for cervical spine pathologies. We will discuss three publications in this field of spine surgery. Which parameters are relevant in sagittal balance analysis of the cervical spine? A literature review Ling FP, Chevillotte T, Leglise A, Thompson W, Bouthors C, Le Huec JC. Eur Spine J Feb;27(Suppl 1):8-15 This study is a comprehensive systematic literature review and a critique of current parameters to help improve the study of cervical spinal balance. According to the current literature, the most proper and reliable parameters to analyze the cervical sagittal balance for good clinical outcomes are the following: C7 or T1 slope, average value 20, must not be higher than 40. csva must be less than 40 mm (mean value 20 mm). SCA (spine cranial angle) must stay in a norm (83 ± 9 ). Laminoplasty versus laminectomy with posterior spinal fusion for multilevel cervical spondylotic myelopathy: influence of cervical alignment on outcomes Lau D, Winkler EA, Than KD, Chou D, Mummaneni PV. J Neurosurg Spine Nov;27(5): Cervical curvature is an important factor when deciding between laminoplasty and laminectomy with posterior spinal fusion (LPSF) for cervical spondylotic myelopathy (CSM). This study compares outcomes following laminoplasty and LPSF in patients with matched postoperative cervical lordosis. For patients with CSM, LPSF was associated with slightly greater blood loss and a higher long-term complication rate, but offered greater neurological improvement than laminoplasty. In cohorts of matched follow-up cervical sagittal alignment, pain outcomes were similar between laminoplasty and LPSF patients. However, among laminoplasty patients, greater cervical lordosis was associated with better pain outcomes, especially for lordosis greater than 20. Cervical curvature (lordosis) should be considered as an important factor in pain outcomes following posterior decompression for multilevel CSM. Analysis of Associating Factors With C2-7 Sagittal Vertical Axis After Two-level Anterior Cervical Continued on page 7

7 7 Fusion: Comparison Between Plate Augmentation and Stand-alone Cages. Kwon WK, Kim PS, Ahn SY, Song JY, Kim JH, Park YK, Kwon TH, Moon HJ. Spine (Phila Pa 1976) Mar;42(5): by the SA and C2-7 angle than by the T1 slope. Two-level ACDF with plate restored more cervical lordosis by obtaining more segmental lordosis at the operated level and was more effective in terms of cervical alignment compared with ACDF using stand-alone cages. In this paper, authors investigated the longitudinal change of cervical alignment parameters including C2-7 lordosis, C2-7 sagittal vertical axis (SVA), T1 slope, and segmental angle (SA) after two-level anterior cervical discectomy and fusion (ACDF). They concluded that C2-7 SVA after two-level ACDF was affected more significantly Spinal Deformity Course, September th 2018 Prof. Salman Sharif With the aim of providing the latest perk of knowledge and training to the aspiring neurosurgeons in Pakistan, the department of neurosurgery at Liaquat national hospital organized the Spinal Deformity Course from 15th- 16th September 2018, in collaboration with Middle East Spine Society, World Spinal Column Society, and Pakistan Society of Neurosurgeons. Prof Salman Sharif opened the course by highlighting the objectives and introducing the speakers of the course. The first session about the basic principles was started with Prof Michael Steinmetz (Cleveland Clinic, USA) via skype in which he systematically talked about neuromonitoring for deformities. Prof Douglas Orr (Cleveland Clinic, USA) then also joined via facetime and expertly taught us regarding when to operate on patients with congenital scoliosis. Subsequently, Prof Onur (Turkey), thoroughly discussed the preoperative clinical evaluation of deformities and growing rod techniques. A lecture on sagittal balance and deformity was given by Prof Salman Sharif (Pakistan), followed by Continued on page 8

8 8 Dr Mohsin Qadeer (Pakistan) talking on the radiological imaging of spinal deformities. Dr. Aman Ullah (Resident Neurosurgery) briefly showed the reduction techniques and maneuvers for adolescent idiopathic scoliosis. The session ended with Dr Sameer Irfan (Resident neurosurgery) presenting the case of adolescent idiopathic scoliosis, a case for live surgery. Prof Onur, Prof Salman Sharif and the team headed to theatre to perform the live surgery on an adolescent idiopathic scoliosis patient with a double curve progressive deformity. Prof Onur showed the free hand technique to apply pedicle screws and also to keep in perspective the size of the screw, while demonstrating how to calculate the diameter and angle of the screw from the CT scan. During surgery various techniques of rod adjustments, derotation, segmental derotation and compression with derotation were shown and taught. The participants also learned the benefits of neuromonitoring intraoperatively, which was the major component of this course. After lunch break, the second live surgery of a patient of lipomyelomeningocele with tethered cord syndrome started under Neuromonitoring. The first day ended with a dinner by the sea in Kolachi Restaurant in which all participants and faculty enjoyed the sea breeze after a long day of learning. Day 2 of the course kicked off with a session on Adolescent idiopathic scoliosis (AIS), in which Prof Doug Orr (via skype) talked about the preoperative clinical evaluation of AIS and its classification. Afterwards, Prof Onur talked about natural history and conservative management of AIS and Continued on page 9

9 9 continued to talk on when operate AIS and how. Following the coffee break a series of lectures were given on adult degenerative scoliosis (ADS). Prof Salman Sharif talked about the classification and sagittal balance in ADS. The techniques of osteotomies for ADS was taught by Prof Onur, after which he continued on prevention strategies for proximal junctional kyphosis. The second day ended with a live surgery on a patient with diastematomyelia and progressive scoliosis.

10 December 2018 Newsletter of Middle East Spine Society