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Presented by the El Paso County Medical Society and hosted by Kathrin Berg.

How often do you get to chat with a neurosurgeon?

Well, today we get to chat with three of them.

Neurosurgery is a surgical specialty dedicated to the diagnosis and surgical treatment of diseases and injuries affecting the nervous system, which is the brain, the spine, the nerves and muscles.

During this program, we're going to speak about perspectives and neurosurgery, trauma, spine and pediatric care.

This evening's program is underwritten by the University Medical Center.

And I want to say a very good evening to you.

I'm Kathrin Berg, and this is the El Paso physician.

Neither the El Paso County Medical Society, its members nor PBS El Paso shall be responsible for the views, opinions or facts expressed by the panelists on this television program.

Please consult your doctor.

Good evening.

Tonight we're going to be discussing and exploring the diverse world of neurosurgery with me this evening.

We have one veteran.

Thanks for coming back.

We didn't scare you away.

And we have two new individuals with us this evening.

And today we have I'm going to start with, zai doctor Saeed, kushi and zai.

She is a neurosurgeon and he is the medical director of pediatric neurosurgery at UMC.

And he's also the a surgeon with Nexus in neurosurgery.

That's a lot to talk about.

So that's your intro.

And in just a minute I'm going to ask you guys to come back and talk a little bit about yourselves.

And then we have, Doctor Marin Sanchez over here and he is a neurosurgeon with UMC Health Care Partners and also with Nexus Neurosurgery.

And then we have Doctor Dave Wang, who's a neurosurgeon at UMC, and he classifies himself to do not as just a county employee.

However, his phone is on the table because tonight he is on trauma call.

So that happens.

We all know that.

We just have to dismiss, dismiss him and go.

So that's a little bit more than just being a county employee.

Just saying.

So, doctor Makoshi, let's talk about what you do all day, every day.

You've been on the program a couple of times before.

You're an absolute joy to speak with.

But as the medical director of pediatric neurosurgery at UMC, dear God, you see a lot of stuff.

So what is your normal day like?

The normal day is all over the place to be entirely myself.

So since we last spoke, we, we've managed to get our certification as an epilepsy center.

So that's taken off quite a bit where we've had children that were traveling many hundreds of miles to get their workup and treatment for epilepsy, and now we're registered as an epilepsy center, which has been a huge deal.

We've taken off with other specialties, spasticity, for example.

And then our very common things that we tend to see here with the trauma is the, brain injuries, the brain tumors, unfortunately.

But, with as far as our center having all the resources needed, we're able to take care of these kids.

So we see all sorts of things day in, day out.

And you get to do that here.

And that's something we talked about.

In the last program we were together to that ten years ago.

That wasn't the case.

And even until very recently that wasn't the case.

So thank you so much for being here, doctor Marin, you are again with UMC health care partners and also with Nexus Neurosurgery.

You what do you do all day every day?

Yeah.

I see patients with different, diseases, including the spine and the brain.

And, I think I just focus on general neurosurgery, whether that's a brain tumor or some non neoplastic diseases of the brain or, spine, you know, discriminations, degenerative diseases, scoliosis, things like that.

So, I think it's still a pretty broad, practice, right now, it helps those that way, the audience and kind of see, when you all are speaking or perspective, you're coming from which is very helpful.

And now just to the, county employee, Doctor Wang, what is it that you do all day, every day, sir?

Well, I truly am just a county employee, so it's really whatever the county needs.

So, you know, a level one trauma center.

It's not just trauma.

We get tons of strokes.

And then whenever you designate yourself as a trauma center, it's almost like, whatever, whatever, neurosurgical issues.

The local community and our catchment is ginormous.

We get referrals from Arizona.

From Arizona?

Yes, we get from Arizona.

We get it.

We get, referrals from, eastern Albuquerque, certainly from western Texas.

And quite frankly, anybody who has neurosurgical issues that cannot be dealt with at their local communities, they wind up coming here.

We do the best we can.

So this begs that question.

The level one trauma center.

How big of a space?

I mean, we are that person all the way through Albuquerque, through northern New Mexico as well, and into Arizona.

So if you think of it, yeah, you know, a lot of times you think of an island surrounded by water.

Well, we're kind of islands here, only we're surrounded by sand, okay.

And we have a significant portion of of individuals that come from Mexico who, you know, may have very serious neurosurgical issues.

And again, sometimes they just come across the border.

We do the best we can as well.

Okay.

Very nice.

So anything that's trauma related I'm going to throw your way at that's okay.

Happy to see it okay.

Happy to see it.

All right.

You guys have great attitude I love it.

Walk in everyone in smiling doctor Marin, you get the first question.

All right.

And so if we're at a dinner table, people think about neurosurgeons.

And I think immediately what comes to mind is like, oh, that guy does brain surgery, right?

Kind of not stops there, but there's a whole nother world underneath there.

And I'd love for you to maybe take that into account with the perspective of everything that we're speaking about tonight.

So we kind of like the base question and answer for the evening.

Yeah, yeah.

I mean, nurse, as neurosurgeons, we definitely deal with diseases of the brain, but, we deal essentially with anything that has to do with the nervous system.

So that's the brain spine.

And also like, nerves that go to your extremities, arms, legs, you know, canes.

So anything that, is related to a nervous system, we, we deal with.

Okay.

And so, and I think it's rare that you're sitting in the room with three neurosurgeons and so on that note, I'd like to kind of ask, I actually going to go to doctor, Makoshi for a moment only because, when I said that you're the veteran in the room.

So when we're talking about kids and neurosurgery and why they would need neurosurgery, what are some of the cases maybe, or just what are some of the things that you see that are most common in what you do with children?

The kind of big common things that we tend to see which affect kids mostly for neurosurgery.

So hydrocephalus, which is as far as a problem with regulating the amount of fluid they are producing in the brain.

So that's a common one that many kids suffer from and either have what's called a Shamet, where they shunt the fluid from their brain to their belly or anywhere else, and they can come in with problems that need to be fixed.

So that's a common procedure that we tend to deal with.

And what age group really looking like very, very young everywhere from newborns even diagnosed in utero before they've been delivered up until they transition to adulthood.

Oh my goodness.

So it's encompassing all of us from pediatric surgeons a common thing that we deal with.

Okay.

Yeah, that's one big aspect.

The others tend to be the brain tumors and spine tumors, although much less common.

Luckily, that get transferred over they present to their emergency department and they're sick and vomiting and they get a scan, they find this tumor, they come here to be taken care of.

And those kids mostly do fantastically great because we can get to them in time and treat them.

Your other common things that we tend to see, our epilepsy, which is common in the community, and finding ways to put in modulation devices to help improve control for seizures.

I would love for you to put a pin in that, because I would really like to speak a little bit more about that.

This evening.

So I'm going to write my little home epilepsy and modulation devices.

Is that what you're saying?

Okay, because I want to spend a good five minutes on that.

Five minutes doesn't seem like a long time for a program.

It is.

I do want to talk a little about that.

And then also, I want to talk in a little while, too, with brain.

And when there's tumors in the brain, how it affects different parts of the body depending on where in the brain these tumors are.

And there's for example, there's, there's a person that I know this week who, actually had to have brain surgery.

Child is seven ish years old.

But it was about there's a I don't know if it was an epilepsy, but they're definitely seizures involved.

But it's an epileptic type thing.

So I'd like to learn a little bit more about that as well.

Doctor Wang so when you talk about trauma and I like to kind of open up that door too.

So as the county employee on call, you get a phone call right now and maybe throw out a case study of what you find has been the most common type of a call that you get in the world of trauma, in the world of neurosurgery, and kind of like being on call.

It's like, you know what?

It is 4 a.m.

and this is happening right now.

What kind of calls are those?

Well, I'll be honest with you.

I absolutely love my job.

Okay.

Because, you know, I'm in a very unique situation with an where are unique skill set where the stars can align.

You could truly make a good, a positive difference in somebody's outcome.

And it's very time dependent.

You mean, so, you know, throughout the hospital where everything's okay?

Are you on or are you off?

Well, I'm really not quite on.

I'm never really quite off either.

So when society needs me, I answer my phone and if it's the stars aligned, then I have the ability to whether it's taking out a blood clot, whether it's taking, whether it's realigning a spine, whether it's decompressing a spine, whether it's washing out a wound, whether it's, decompressing a bad stroke, it can be any number of things.

But the, the practice of trauma, neurosurgery or acute neurosurgery is fairly straightforward.

Okay.

You know, it is to you.

So explain it to us.

They don't know that.

Well, okay.

So truly, if you think of if you think of what we can do as a neurosurgeon, I wish I had the Star Trek tricorder where I can wave it over somebody's head and make the brain okay again.

Well, we really don't have that scenario, right?

So what we can do is we can decompress, we can stop bleeding.

We can really.

Right.

And again, if you really break up neurosurgery into these very basic components, that's really all we do in any field of neurosurgery.

So as I explained to my to to some of the patients that that the, that, that I wound up operating on, we're essentially plumbers and mechanics.

Yeah, you're plumbers are mechanics.

And that's a nice way of putting it together.

Two and I'm thinking, for example, when you get the phone call in the middle of the night or at 3 a.m.

or during this program, what is the most common call you get?

Or maybe this is more the question, what are the symptoms that present for you to get the call saying, hey, we need you to come check this out.

Maybe that's more of the question.

Truthfully, a lot of trauma is surgical.

Okay?

A lot of trauma is just observation.

You know, maybe a few scans, just, medical support.

Okay.

But the ones that are acutely surgical usually involve some form of decompression.

Okay.

Because that's, that's really that's really our value.

Okay.

When the brain is compressed, it's angry, it's tight, it's nonfunctional.

And then that is really your time to intervene because you have a very short period of time to get that pressure off.

You get the pressure off shortly.

They have a potential of doing very, very well, especially in the pediatric population as a doctor, because you will test to, and then if you wait, sometimes they don't do quite as well.

So that's the perfect follow up question there.

So if you have a certain amount of time, what is it that happens if you don't get them within that hour or within two hours?

What starts happening with.

So they have these cutoffs half an hour, 1 hour or 2 hours.

But the truth of it is when you get that call, you're in there as fast as you possibly can, and the system is working as fast as they can.

And, you know, our county system can be can be faulted for any number of things in efficiency and things like that.

But the truth of it is when the county is really needed, I seen it in action.

The county comes together and we notice that with so many different things to we have.

Thank goodness we have a great relationship with city and county and all the independent hospitals and the county hospitals.

I mean, I think that people sometimes don't realize, I mean, it's El Paso, right?

We all do kind of stand in and do it together and get it together.

So I am in complete agreement with you on that.

Doctor Martin, I think that we should maybe open up the idea about lumbar conditions and the spine, because, you know, you got that that great spinal cord that's going through everything that makes it all the magic happen in all of our bodies.

If you don't mind explaining brain spine, how the brain communicates with the spine.

And what are some of the issues regarding the communication with the two?

Yeah.

Simple way to think about is that the brain and spinal are a single unit that communicate with each other.

The the spinal cord is how the brain, sends the signal to the to your arms, legs, and, makes them work.

So, in order for them to work, the brain sends a signal, travels through the spinal cord, gets the nerves, gets the muscles, and then you move.

So some of the common problems that we see in neurosurgery is that somewhere along the way, a nerve gets injured.

Whether that's because, there's a, for example, a herniated disk that it's pushing the nerve, making that nerve irritated and happy and eventually nonfunctional or sometimes just unhappy and can be the cause of a couple of those.

Yeah, I'm sure we I know we all probably all do.

Yeah.

So that can cause pain.

That can cause dysfunction.

It can also be other things.

It may be just, with time, your spine suffers a lot of wear and tear and starts changing shape.

And, again, you end up with the compression of the spinal cord.

Or sometimes it just, the joints get weak and you end up with a lot of pain from instability in your spine.

It can suffer in multiple ways.

And, and more and more of those conditions, are more, prevalent in, the older population.

As we age, we tend to accumulate some of those, changes.

So as the plumber and the mechanic, when these issues start coming about, I'm scoliosis, girl.

I have it all my life, so I'm crooked everywhere.

If you look at these bones, they stick out a little bit.

But I know that as I age, and I have noticed as I age that there are things that don't function as well as they used to, you know, in general, when neurosurgeons come into play and there's spine again, there's brain, but I want to concentrate on the spine right now.

What are some treatments?

Feel free to give the condition in some treatments and how the treatments are performed with some of these conditions.

It again, it depends on the problem.

Right.

If you feel free to find a case study in the back of your head or your name, just kind of walk us through absolutely what it was and what you did.

I'll give you some examples.

Again, some people have herniated discs.

You, lift a heavy box and all of a sudden you have a disc that just ruptures and starts pushing on your spinal cord or nerves and, you know, you're pretty happy, you're in pain.

And, sometimes it goes away on its own, but sometimes it doesn't.

And that's sometimes when neurosurgeons need to intervene and, help with the decompression of that nerve.

And there are multiple, multiple ways of treating those depending on that specific, characteristics of, of that disc.

But that's when neurosurgeons, get involved, when the problem doesn't go away on its own, when medications or physical therapy or other smaller interventions, injections, things like that are not, enough to to treat the problem, alleviated problem.

But sometimes necessary neurosurgeons are not needed to the problem.

It just goes away with time.

So it depends on the condition.

There are many others.

Sometimes your spine can just, like, start losing its strength just to keep it simple.

And, your bones can start moving in abnormal ways, and that can cause a lot of back pain.

So, you know, eventually medicine gets to a point where it's not no longer helpful.

And, neurosurgeons can help with that.

And so what do you do when that is the case, like, physiologically, what do you do in the surgery that helps out with that condition?

Again, it depends.

But common solutions for these problems, for example, herniated disc.

You can take out the disc.

Sometimes the problem is a little bit more, complex.

And there's instability in the spine.

So you can decompress for, for a disc, that is stable.

You can decompress, take out a disc, or when the spine is unstable, then that requires sometimes fusions.

And when you think of that is putting screws, rods, cages in the spine to help it, regain some of that strength or stability that has been lost, over time.

Okay.

And if there's disc taken out, do you put something in place of the disc or is it now just your disc list?

Sometimes, you can take little pieces just enough to, achieve a positive outcome without destabilizing the spine.

And it's it's complex.

Sometimes, you have to make a decision about when to take it out and when to just take a little piece, when to take it all out and put a cage wire or feeder sheet and things like that.

It just depends on it.

What is that?

And you're keeping?

Yeah, yeah.

It's usually you can think of it as a little spacer that replaces the, the disc.

Normally the, the disc lives between two bones and it's like a, like a cushion and also spacer between your two bones so that when the, the, the bones in your spine move, they, they help maintain the normal space and make enough room for, for your nerves to come out of your spine and just maintain the, the normal, shape of your spine.

But when you take a significant portion of the disc, you lose some of that, stability that the disc provides.

And you have to actually take almost all of it out and replace it with something so that the spine doesn't collapse or move, in, an abnormal way.

Okay.

So here's another question has to do with the spine.

I, for example, have bone spurs on quite a few.

My neck, apparently it's from an injury years ago that I didn't know about.

But that is truly causing some nerve issues in my neck, so I haven't gotten to the point yet where maybe I should, But surgically, what could somebody do when I get to the point where I need surgery or what might that be?

And doctor Wang, I'm going to ask you because I'm going to pretend this is a trauma or or something.

But what might be able to be done?

Because bone spurs.

Maybe we can explain why a spine, a bone would want to create a spur for protection of what?

And the what can we do after that?

I am not operating on you.

Okay, so, so, you know, it's human physiology.

Okay, so the spine is not a single bones or a series of bones.

It's designed to move a little bit.

Okay, just as with arthritis.

Okay?

If a joint is inherently unstable, the joint tries to protect itself by growing.

Okay.

Just like the spine has multiple bones, every bone connects with another bone with the joint.

Okay, your spine is as good as it's ever going to be when you're born.

And as we age, everybody's spine deteriorates.

Great.

So, myself included, have time, myself included.

Okay.

Yeah, but I don't consent to any surgery either.

Right?

Right, right.

So, so as we age, the discs collapse.

You get spondylolisthesis, you get a little bit of foramen or sinuses.

And the difference what that means is that you have a spinal column, and then there's spinal stenosis, which is tightening of the center of the spinal canal.

And then there's fragmented sinuses where the little nerve roots that come out the side.

Now MRI's are very, very sensitive and sometimes they overdiagnosed.

So if you were to MRI everybody in the room, a good percentage of them had severe spinal stenosis somewhere from an acidosis somewhere else.

Okay.

Now that doesn't necessarily mean that it's surgical.

It just means you had it.

Now for a subset of the population, the spinal stenosis becomes symptomatic, in which case it may require surgery.

Surgery is always the last thing you do, not the first thing you do.

So there's this entire gamut of conservative treatments a physical therapy, a pain management or stretching.

Right.

And then quite frankly, if you get better without us.

Perfect.

Right.

And we're here if you need us.

I like you.

You're fun.

Okay.

So when when I need you, I'll be there.

But I know that eventually, for example, you're right there.

But if you sat right there, I would not be able to look at you unless I turn my whole body that way.

And I know quite a few of us sort.

You know, there's only so far I can turn my neck.

And it has been that way for 4 or 5 years.

So I keep thinking to myself, eventually I'll only be able to look at you, and then I'll really have to turn my neck to look at you.

So these things are curious to me because to your point, my spine was perfect when I was a week old.

But as we get older, things start happening, and so I'm going to put that on the table for a little bit, because I do want to talk about, some pediatric issues.

I do want to talk about epilepsy, but maybe not even just diagnose epilepsy, but seizures in general in children, what causes them?

I know there's a series of different things that causes them.

I know sometimes that they're a lifelong thing and sometimes they're not.

And I'd love for you to maybe go into what that might mean for epilepsy.

And there is a whole classification of kind of putting it into different boxes to help with that.

Okay.

So there's lesion all, for example, where there is a tumor that's growing inside the brain that's causing the seizures.

There is where the nerves didn't quite develop the way they should.

And they start to cause seizures somewhere throughout life.

There's epilepsy syndromes that sometimes go all the way down to has sodium channel, a potassium channel at a cellular level that caused seizures.

And then there are things that after trauma, after infections that can trigger seizures.

So they kind of put in that category is just to help us know what caused them, but also how severe they can be and to help with treatment.

So things that are very localized to a certain area of the brain, usually we'll consider them, for example, taking out that area of the brain that's already causing seizure.

It's no longer helping the brain to do what it's supposed to do.

All it's doing is pulling it back and just irritating it fine enough.

Other times there's multiple different areas causing the seizures.

We can't take out the whole brain.

You need your brain so that we talk about things like modulation.

So modulations.

We're trying to interrupt those signals for the epilepsy.

And they could be things like vagus nerve stimulators.

The vagus nerve having as far as most connections in the brain than any other as far as central nerves or directly into the brain tissue, which is the RNNs and the deep brain stimulation that the two other things that we put implants into the brain itself to disrupt those signals.

And sometimes we've reaching as far as a very good success, 80 to 90% control.

It's not everyone, but sometimes, at the very least, we get an improvement that you're not having seizures every day, that they're not horrible seizures.

So expand on that.

So when we've got these, these, sensors, if you will, on the brain and do then try to develop or somehow have the child have a seizure.

You do wait, do you like, how do you how do you experiment with that?

That's a terrible word.

But you know what?

I'm.

How do you know with that?

How do you know what is causing it?

And if you're at the right spot and you have the right position.

No, that's a fantastic question.

And you start with kind of that work of of getting your basic brain imaging to see what can you see on an MRI scan?

Is there something structural that there that gives you the answer?

That's not the case.

You can do things called Pet scans and you're trying to there's an area of the brain that's not quite absorbing or taking in as far as the energy that it should.

It looks odd on a scan sometimes that's an order, and then we move on to a bit more invasive.

We'll put tiny, thin electrodes into certain areas of the brain to map out where those seizures are coming from, stimulate those little electrodes, know what they control, and then come up with a plan.

Okay, if we put electrodes in this area, you'll probably have a good response.

Or we can take this out safely that we shouldn't be touching.

Let's do a modulation.

So could those electrodes like the going forward five years from now, is that something that is consistently in the brain or like you said, that that portion is removed like an ablation almost?

Or how is the treatment for future and long term effect in those situations?

Probably one or the other.

A lot of people, for example, have a specific area.

And now instead of doing an open surgery, we do laser ablation where we have an ablation can work pretty well.

But then if it's multiple other areas, then the electrodes would stay in.

If they start to work, their effect over time actually gets better.

So we see a seizure improvement within the first six months.

At a year we see them to better that two years even better.

So that modulation continues to improve over time.

Okay.

And all we have to do is replace the battery.

And this is the magic of children.

And some things just kind of start helping.

Thank you for explaining that because there a lot of different questions there.

I like to talk about cerebral palsy.

Palsy as well as I feel like that is often associated with children.

What what what's happening there?

And cerebral palsy is a big name for so many different things.

Okay.

All it is, is an injury around the time of birth that the brain, any type of injury, whether it's not enough oxygen, whether it's a bleed, whether it's any other type of trauma, but it's happens to the developing brain that we have long term effects.

All that umbrella cerebral palsy, which is as simple as a kid that has a little bit of stiffness in one arm or as severe as someone that's come by to a wheelchair.

So it's a big spectrum with one common name, but there's things that we can do about it.

There's cerebral palsy that's associated with epilepsy.

We treat it the epilepsy way.

There's spasticity where there's so stiff.

We talk about treating the stiffness by cutting the nerves in the spine to make it a bit more loose.

So now they move more freely, putting in pumps that affect the spine directly and also lead to relaxation.

So it can be a life changer for a lot of these kids that they're developing.

So here's the question.

And I know I've I've already acid on this side as well.

Symptoms.

Symptoms symptoms.

So when you're a child you cannot explain your symptoms and or whatever.

Your feeling is what you've always felt.

You don't know it's not right or not right.

So as a parent, who may not know that their child may not be acting what the word of normally would be, or a typically developing person.

Give me some samples or some examples of when parents have come to you and said, you know, I feel like this just isn't right, or I feel like that just isn't right.

What are some of those that you've seen?

The big ones are we have the milestones that we should be reaching, but there's a lot of variability of that.

But that's a good marker where if you're meeting your milestones consistently, you've probably should be reassured.

If you're having delays in certain milestones, then there's different causes.

You're not sitting on time, you're not standing on time.

And that on time is still very wide.

You have to give each child as far as their own leeway to when they want to do that, but at one point it does become too late.

Easy things or quote unquote easy things are preferential handedness.

For example, children should be using both hands.

So if within the first couple of years are using one side, not the other, but that's a big warning sign that something must be going on behind the head.

Growth should be following as far as its own curve.

If the head starts growing too fast, the head the child just irritable and crying all the time, that's a warning sign.

Something might be going on in the brain nausea, vomiting.

A child that is walking and then now is not walking anymore because they're too unsteady or they can't stand.

So regression is another big red flag that something might be going on.

So those are some kind of big markers that something's not right.

We probably should get checked out.

Okay.

That leads to the question of what's causing it.

And there may not be an answer.

I'm in full respect of that.

If you could answer what's causing it?

What might some of those causes be?

If we're talking about cerebral palsy, usually once we do a scan, we'll find some evidence of old injury scar tissue.

So at least it tells us a hint that somewhere at our own birth, there was a little bit of a bleed.

There was something that was missed a stroke event.

But because we're kids, they're not as obvious.

But we're seeing the consequences now.

And it's not surprising.

We have a child that's doing wonderfully well and see a big stroke on the MRI scan, and they look absolutely fantastic because kids do that.

So sometimes it's little heads.

I kind of show up where they're just not moving that right side as much as they're moving left.

So if a parent comes and I'm thinking that you're not the first line there, but a parent comes and whoever it is, it's going to refer a child to you, the person that is looking, whether it's an internist or someone in the, in the department, when they are trying to diagnose one of the question you were talking about, you know, sometimes one side works better than the other side.

Is there pain involved in any of this?

And again, if it's a child, I'm going to say before speaking, age, I guess I'm kind of asking the exact same question.

No, it's a good question.

The kids are usually happy.

The kids are doing fine.

They have no concerns whatsoever.

It's just they're different.

They're not quite if they have older kids.

Well, my other kid was doing this at this age, but they're not quite doing that.

Or I've noticed that they're always reaching with one hand.

They're not reaching with the other.

All I know is when I'm changing the diaper, the legs are a bit stiff.

So all these little hints start to come out so we can do the screening for it when they come into clinic.

And if we meet certain markers, you meet the diagnosis of having some form of cerebral palsy.

But sometimes it's so subtle because the kids are just exactly their brains are now.

Yeah, that's kind of what I'm thinking.

Okay.

All right.

Thank you for that.

You mentioned stroke Doctor Wang.

I'm going to throw that your way for now.

But feel free anybody to kind of pop in on that.

So, stroke and issues with the brain, neurosurgery, etc.. So you talked about time, which is why I want to bring this to you.

And I think that's so important with a stroke.

And I know there's hemorrhagic strokes, I know there's a ischemic stroke.

So I know that there is differences between the two, but feel free to take it from there and describe where you all would play a role with which kind of stroke.

Well, we are plumbers and mechanics.

Okay.

So as far as the plumbing goes, that's really not so much neurosurgery and more neuro interventional, right, in that it kind of belongs in the realm of stroke neurology, where there's that, that, that type, where people start to have ischemia strokes and then the deprivation of oxygen, it's in the brain.

And the time it takes for that, that, that oxygen to be reestablished, usually by reestablishing blood flow.

And that can mean something like giving antithrombotic agents.

It could be, thrombectomy where they're mechanically going to go up a blood vessel.

If I take out a blood clot to reestablish that flow.

But there are regimented times that that they have to and criteria that have to be met for these to occur.

Okay.

Now for a county employee like myself.

So I support a lot of these services.

Okay.

So so people who have a schematic strokes, right?

The scheme and the ischemia of the stroke sometimes the brain just kind of small in a schematic stroke is like when we're looking at so blood versus ischemic.

So if you don't mind throwing that it actually works.

They're actually very similar okay.

Because again we're just mechanics right.

So from a mechanical standpoint I can't fix brain tissue.

But what I can do is I can remove material to increase chances of survival.

Okay.

Or I could take out blood clots or I can stop bleeding.

So things like ischemia, strokes, you know, typically that's not a role for neurosurgery, an acute standpoint that's more stroke neurology to reestablish blood flow, stroke neurology to reestablish blood flow.

Okay.

That makes sense to me.

So yeah.

But once brain tissue has died okay.

It has a tendency of swelling.

Right.

And then within 2 to 3 days the swelling could be so much it starts to increase the brain because the brain is, is confined in a cranial vault.

And if there is increases in fluid from swelling, then that will increase the pressure and start to displace tissue.

And if it starts to displace tissue so much, it can be life threatening.

And that is our role.

So while we can't fix the inciting stroke, we can look like, oh, we made these patients better.

If I remove them skull temporarily to increase the chances of survival to occur.

And then they call that a craniotomy.

You know what I love about Doctor Martin right now?

Everything that you're saying, he's like, he knows what he's talking about.

Yeah, I really am.

So that's like, I'm going to go to the doctor about it right now and go, okay.

Yeah, I agree with that.

I agree with that.

So feel free to add in on that.

So yeah.

Removing and we hear this a lot.

You know, we hear I guess with a lot of brain bleeding, so to speak, you remove part of the skull and people are like, what do you mean you drilled a hole in there, remove part of the skull.

So let's talk about that number one because it's kind of gross but cool to talk about.

But number two, it's a real thing.

And like you said, there's swelling.

You have to go into an induced coma for a while to get things.

Just take that wherever you want to run with it.

Yeah.

Yeah, that's exactly right.

Like you, for those kind of strokes, that's essentially the only thing we can do is just try to prevent, the pressure on the normal brain from the brain that is swelling from the stroke.

So you do things such as, like taking half of the skull off temporarily, to just create more space for for for the brain, for the healthy brain.

So it doesn't suffer a secondary injury from, from the initial process.

So that's that's one thing.

And then, you were talking about, hemorrhage or, hemorrhagic stroke.

That's another kind of stroke that we deal with.

And that's when you have bleeding into the brain or around the brain.

And, when that happens, it's essentially the same process you have bleeding that takes up space and starts pushing on the normal tissue.

And, that pressure can cause a secondary injury on the, on the healthy tissue.

So, so we try to avoid surgery whenever we can, but sometimes, without surgery, you're just going to have more, more issues.

So that's when we come into play.

We can make craniotomy meaning, small windows in the skull and look for those clods, evacuate them.

And then if, there's a significant relief of the pressure and we kind of know when, that decompression where evacuation is enough to, allow the brain to heal, you put the skull back on and, just, you know, nurse patients through, through the stroke recovery.

But there are some times when, when the injury is so big that there's even when you take the clot out, there's still swelling of the brain or a buildup of fluid in the brain.

And in those cases, you have to do additional things such as, again, leave the skull off or put, some drains to, drain some of the, the fluid that builds up in the brain, like so.

If you don't mind, I'm going to ask you get specific there.

Yeah.

Because it is the month of October, we can get a little gory.

Okay.

When you're talking about stents in the brain or somehow draining some of that fluid.

Yeah.

Describe to me how that's done.

And and also, this may be too simple of a question, but what is it then that helps the brain with the swelling you were talking about?

When there are parts of the brain that die, it tends to swell.

Does that ever start going back?

Does that part of the brain removed?

I mean, where does the after effects of this come later?

Yeah.

So the, the pressure or the brain keeps swelling for, for several days, usually five ish days.

Six, seven.

You know, every patient's a little bit different, but, that's, up until that point, the brain keeps swelling and swelling and swelling.

So, if you are able to nurse, patients through that process, then after that point, the brain sort of like, starts going back to a more normal state.

It's not going to be completely normal because it suffered a stroke.

But, some of that swelling starts to go away.

And there's some things that you can, do to help the brain.

For example, the the brain is very sensitive to your, sodium levels.

So you can play a little bit with, sodium levels to help with that.

Swelling, to try to reduce it a little bit and that sometimes can be enough to get patients through, through that process.

And then in terms of, for example, draining fluid, we do a commonly do a procedure that it's called ventricular ostomy, where you make a tiny hole in the skull, and you pass a catheter into the ventricle, which is the space that contains most of the fluid volume, not mostly fluid, but a big portion of the floating in your brain.

And you literally put like a little tube that works as a hose, and you drain that fluid into a bag.

And, as the pressure, as the pressure inside the skull increases, you push out more fluid.

Interesting.

And that can stay in for how long?

Or on on average, how long that something that stays in for some days.

It's something that you want to remove as soon as possible.

But, they when patients have hydrocephalus from strokes, or buildup of that fluid, it tends to stay for like several days, like a week, two weeks, sometimes longer, three weeks.

And sometimes the problem actually never goes away.

And they need Sean's.

And so that's a permanent implant that accomplishes the same goal.

But it could be a permanent implant.

Yeah.

I'm staring at you as I think.

How how would somebody go about their life with that?

It's it's actually quite complicated surgery.

Yeah.

Okay.

Maybe not in medicine in general, but in neurosurgery it is very common.

Yeah.

So here's a question I usually say for the end of the program.

And I still will ask at the end of the question, but I always I always think to myself, okay, all the stuff to me is new because I'm a layperson.

How long has has some of these practices been in play?

And I know you and I talked about this a lot during the last program.

So many new things in the world of epilepsy and seizures in and children.

But ten years from now.

And don't answer it now, but I want you to be thinking about this because it's how we're going to close a show ten years from now, 20 years from now.

What do you see coming up that's going to help you?

So that's going to sit on the table for you guys.

And now you and I are going to talk because we're going to talk about, plasticity, because you talked about that a little bit earlier and a selective, dorsal revise, it automatically arise out of me.

Exactly.

Thank you very much.

Because I have a written down here, which means I really do want to talk about it.

And I know it's crazy, but we only have 17 minutes left in the show, so let's cover some of that.

So that goes into the cerebral palsy and spasticity.

Okay.

Your brain's not telling your spine that you need to slow down, move a bit more smoothly for your lips.

So if it affects the legs more severely or they're so stiff because every time you touch them or try to move on, that spine just triggers a response from the muscle that you can't do anything.

What we can do is that we can go into the spine, single level in the spine, where the spinal cord ends and those nerves come out to the side.

We take the sensory nerves and take about two thirds of those, the very abnormal ones, and cut them hurt.

So you still have sensation in your legs, but that circuit that's causing that stiffness goes away and the lights are now loose.

You can imagine a child living their life with spasticity that can't run as fast.

Trips are very severe.

We're just getting them out of the wheelchair.

To change and take care and made is extremely difficult because they're so stiff it makes a world of difference worse.

Those legs are loose, so that's basically what the result of me is.

And we've had that for quite some time.

The early reports came from the 1900s.

They kind of went away for a bit as medications came in 1970s, 1980s.

From as far as Africa came to here.

Techniques have changed a little bit, but it has been around for quite some time over as far as 3035 years of practice.

So we have long term evidence to know that this works, that it works for a long time.

Well, as you're explaining, it's very intuitive, you know, to hear you saying it in that way.

And then let's talk about nerve regeneration.

When does that stop being a thing?

I know we have the best spines, and we're a week old.

But there is a newer generation regeneration.

But I don't know how big of a deal that is.

I don't know if that even plays a part.

And you're smiling and nodding.

So I think that's a great question.

It's still an area of research of trying to build new nerves, but what we can depend on is plasticity.

So the way we understand it is that you can form new connections, even from your right side, to control the right side of the body instead of the left.

You take kids that are very young, for example, and they're speaking on their from their left hemisphere.

You do a disconnection early enough in life.

They can pick up speech on the other side because it's capable of doing so.

They couldn't move after as far as you take out one hemisphere.

But there.

So yeah, there's one side works through both and they're still living there like to the walk the impossible.

So it really is plasticity where you can form new connections in the brain.

And some kids do really well.

As you get past eight, nine, ten years old, that ability gets less and less as we get older.

Okay, so there is that golden threshold.

And when you start to get really going fast.

Yeah.

Okay.

Nicely explained.

Before we go into that area where I and I said earlier before the show, is there anything that we haven't talked about that you do want to talk about?

But in the meantime, I'm gonna throw this out there that all these neurosurgeons that you see here today are part of the region's largest team of neurosurgeons at the El Paso County Hospital District, providing advanced care for complex conditions affecting the brain, spine and nervous system.

I just had to make sure I got that out there.

So on that note, and Doctor Marin, I'll start with you.

But again, this is definitely a part of the program to where feel free to hop in on each other.

But, coming here today and I have my questions in front of me, but if there's anything that you want to talk about that we haven't talked about yet or something that you might want to expand on, that any of the three of you had said, this is kind of the time to do it isn't the worst feeling in the world is having this whole live hour and then you said, oh, but if I only had time to say that, so this is that that golden time.

Yeah.

Who?

I'm not sure.

I think we're having a good conversation.

You can totally pass the ball to someone else and they can bring it back to you to share.

But please, doctor Wang, you want to take that?

All right.

Sure.

All right.

Sure.

So there are a few years back, right.

And then, you know, I, you know, I, we all have, appointments to Texas Tech as well.

So we have medical students that rotate, and I really enjoy that.

That's fun.

I enjoy working with the students because they keep you young.

Right?

Yeah.

We keep you on your toes and we have them on this program.

There's always a perspective that I never thought about that they bring to the table.

I think they're fantastic.

Yeah for sure.

So so I had one a few years back.

Right.

And then you know she commented to me, you know, we have this thing called the overboard, right.

Tracks what we do.

And then one thing since she mentioned to me was, you know, gosh darn it, Doctor Wang, you know, I see, you know, I, I don't I never quite see you on the board but always seem to be involved with all these cases.

So I go, well, you know, I guess, you know, when things come in, I just kind of do whatever society needs me to do.

So.

So you're so.

You mean you're like Batman?

Yeah.

So I got called Batman.

Nice.

Okay, that's the takeaway for the evening.

Yeah.

So, you know, and you also, you also mentioned a few.

You know what?

Where where would I see myself ten years from now?

I'll be very honest with you.

Probably doing the exact same thing I am now.

Right.

And it sounds a little antiquated because, like, with all this time and technology.

Right.

And, you know, I think I think doctor McCosh, you will.

Well, that's to this a lot of it's rehashing the same things we've always been doing.

Maybe not.

Maybe not necessarily.

You know, you know, the exact same way because hopefully within ten years we would learn a thing or two, but the same thing, only better.

Right.

You know, more accurate, less bleeding, you know, shorter, shorter duration times, you know, better anesthetics, better aftercare.

Right.

But neurosurgery is there a surgery?

And I think neurosurgery is essentially will become an interesting, again word because you said you're you're manipulating you.

You are a mechanic.

You are a plumber.

And I always think to myself to when I asked ten years down the line, 20 years down the line, I think about what research is happening like right now as we're speaking, things that you might be studying or going to conferences for, but you can't really bring it to fruition yet because they're kind of just sort of in the idea of, well, maybe that's going to come either to United States that might be practicing somewhere else in the world.

So those kind of things are what I think is, is fantastic to kind of close these shows us like, what do you see coming up and doctor me, I'm going throw it back to you or doctor McCosh, I can throw it to you.

But that kind of thing, like, what do you see, in this, in this arena?

Yeah, I agree with what Doctor Wang said.

I think, the technology is going to get better.

I think the procedures are going to get a little bit shorter.

We're going to need, like, better microscopes, better tools in general that are going to allow us to do the same thing just a little bit faster, a little bit safer.

I think, where there is maybe a lot of opportunity, maybe you can talk about this is neuromodulation because we're learning a lot about that.

The devices are getting better.

We're able to stimulate, in different ways, more areas or areas that we haven't stimulated before.

And we're getting results that we never thought they were possible.

So I think that area is, going to evolve a lot.

I don't know where we're going to get.

Other than that, I think the rest of neurosurgery is going to be similar.

I think, we're just going to have better tools, but, better tools.

But you know, the, the, the, the surgery that we're going to perform is going to be very similar, I think.

Okay.

All right.

So let's do talk a little bit about neuromodulation and, or and what you see coming up in the future as well, there are a large number of trials going on to use modulation for many things.

So people that are traumas that have a decreased level of awareness, so they've had such a severe injury that they're kind of they're they're not sort of there and putting electrodes into certain areas to get them more aware and all that.

Still research you talking about all in the brain stimulators in certain areas, targeting areas that are responsible for our awareness and seeing if we can stimulate those areas.

Has everything's been traumatized?

Does that make a difference with some interesting results, we'll have to see long term stroke patients and their recovery getting as far as some strength back and also putting stimulators in certain areas before.

Let's go look at that okay.

And then moving on to behavioral things.

Obsessive compulsive disorder depression other things that again all research based but all down the avenue of things that we might be able to treat that we weren't considering for modulation before.

So people are trying things.

And of course, to be safe, you have to see that long term data.

But a lot of things in the work of just stimulating different areas of the brain and finding out what the brain could do, you know, you hit on something that I would really like to do.

The powers would be I would love to do a program on mental health and the electrical stimulation about all kind.

I feel like I've been hearing more and more about that over the last several years, and I'd like to know where we are was at, and I and I attribute that to movies from long ago when that was not a good thing.

And you talk about One Flew Over the Cuckoo's Nest to talk about all these things.

When people have these images in their head about not great outcomes, but I think there's a lot coming forward and, hopefully we'll be able to do something on that soon.

Stroke recovery to me is very interesting and so when you talked a little bit about that, because and we've all been those people throughout our lifetimes, we've known the arts, the NGOs, people who had a stroke and then they're paralyzed on one side and that's it.

Finished.

Finito.

I think that that is changing a little bit.

And you mentioned a little bit about that.

Can you expand any more or maybe we're not there yet.

Well, the best I can tell you is that the research right now is a very small group, and I'm talking about 3 or 4 patients.

I see we're nowhere near implementation, but there's hope.

They're exactly showing promise that people that do recover with physiotherapy, that do some improvement.

So they're gaining something back, do a lot better.

When they had physiotherapy in a stimulator.

Now whether that happens in everyone, whether they're one out of every ten is going to get that benefit.

We don't know.

But something up the avenue that they're looking at okay, I love I'd like to do the show again in a year and to see maybe two years and see what all has changed there.

So here's the magic question that I know everybody is tired of hearing, but I'm curious.

The world of AI, it affects some disciplines of medicine a lot more than it does other areas of discipline.

But let's take it to neurosurgery.

And I. What are you all seeing?

What are you all experiencing?

What do you like?

What do you not like?

And I'm just throwing it out there because it's the topic of the day.

And if I didn't throw it out there, I'd not be doing my job.

So who wants to to take that out?

Doctor Wang, go for it.

So, AI is.

It's just a fancy way of saying acquisition of information.

Okay, so there used to be a time where you had to have specialized knowledge with years of training and schooling to know what these fancy words mean, and those days are gone.

Okay.

Because anybody with a cell phone can type in symptom or diagnosis and get it, get not only a diagnosis, but in the treatment plan.

So in my mind you can either, you know, hide, you know, claim that it doesn't exist or embrace it, embrace it.

Right.

So for every patient I encourage them to take my diagnosis, especially a bad one, and I encourage them to put it in their phone and in front of me.

Read the result right.

Because it is part of our job, I think, is to help them process that.

Right.

So AI is the tool like anything else.

Right.

And then they're going to have access to and they're going to use it whether or not you want them to.

Right.

So in my mind, I think it's very powerful because then then the physician, the patient could be on the same page looking at the same information, and then it could be not my treatment plan, it could be our treatment plan.

Right.

So I'm going to I'm going to go that further into ten years ago.

So when Doctor Google came to the table, every time you'd go to, you know, and you say, well doctor, Google said this and Doctor Google said that, when and I remember even physicians on the programs like, well don't bring Doctor Google to me.

Listen to me first because Doctor Google may not have the correct information.

And I think that's something to I want to ask that question of that.

When you talked about information acquired, acquired information, when and where and I love the fact that you said, do it in front of me, like, look up this stuff, do it in front of me, the doctor, so that I can confirm, you know, trust, but also confirm, etc., etc.. How are you Doctor Marin?

Has anybody talked with you about that?

How are you handling those kind of questions from your patients, etc.?

I love that I haven't encountered that situation.

Too much, but obviously I've seen patients who have looked up their symptoms on internet or, you know, AI platforms.

And, I think it's good that they're getting informed.

The, the only the only problem that I see is that sometimes they get information that may not not be accurate, and information that is incorrect can be dangerous.

But, you know, as long as, we do it in a way that, helps supplement, the correct knowledge, I think it's a it's a great, a great tool.

We just have to be careful because information can also be dangerous and can.

And the question too, is now I feel like for the most part, in the medical world, at least through some of the programs we've done, it has been very helpful with diagnosing, and it could be it could be breast cancer and how imaging is done, and that it's not just the naked human eye looking at things.

It is now I in some kind of magic looking at diagnosing, oh do you see that is I mean obviously that's a plus.

The doctor will call you if you can maybe talk about some of the ideas of diagnosing, as you were talking about, to a lot of clinical stuff, you know, you're coming with these symptoms.

This is what you're seeing when you go in to actually do a diagnosis.

And the imaging that you're using is AI being used an awful lot more now and is it helpful, etc.. It's definitely coming into play with different softwares.

Saw we didn't think of it before.

So you take epilepsy and you're monitoring several different areas, and now you have a software that can kind of put information together that you can't see in a 360 fashion.

Tell you, it looks like this is the network that's forming the seizure, very useful in softwares in that regard.

You come to other things where it's reading scans and etc.

and for people that maybe aren't specialized, that are reading brain images, at least it brings up the standard where maybe not missing as many things.

But if you compare it to as far as an Or radiologists, then they might be a bit better.

Or they know what's significant, what's not.

When it comes to the diagnosis, it's key words.

So someone has a little bit more fluid in the brain.

We'll call it ventricular make a big ventricle.

But if you look it up, the report from the radiologist says hydrocephalus suddenly you're dealing with an emergency.

Oh, that one might be your difference.

And that's where it can be a bit troublesome.

I read this and it says hydrocephalus.

So my child might lose vision or could get even worse.

No, it's actually ventricular hydrocephalus.

Is that so?

Single words.

Because all I does is pulling all this information from different reports.

Right.

Based on that one word, which is very accurate for that one word.

Exactly.

Is that your child?

You know what I'm thinking?

That too.

I'm from Germany.

I just got back from Germany a couple of days ago, and we talked a lot about the amount of words that you have to describe one thing, and English has a fewer amount of words to describe various things.

So I had thought quite a bit to when you're prompting an AI, what language you're prompting in and what words you're able to use, and in German you can put very specific like 4 or 5 words in there and the English only have one word that kind of describes it.

And so I think this through to with medicine and how that works going forward.

We have we have the two minute warning at this point.

Is there anything else you want to throw out there before we, say the thank you's to the entire world?

Nothing I miss anything.

All I want to say is that we are here and we are here to help all of us trained at fantastic places to bring our expertise to El Paso.

So we are here to help you.

So if people have questions, reach out.

I love that kid.

They where would they reach out to?

Is there a website?

So through the website you can always contact the hospital.

And that way you know the number, the fax number for the clinics, which is always the most useful for a physician to send.

Okay.

Most of us are located on those websites with our bios in case anyone has any questions.

And there's multiple ways through the website to get through to us.

So now I would just say the University Medical Center, Oakland University Medical Center website again, UMC health Care Partners also, and the UMC and Nexus Neurosurgery Group.

And so thank you so much for having all of that put together.

If this is the, first and only time you've seen the show and you want to watch it again, there's three different ways you can do that.

You can go to KSU is TB, which is being aired right now.

And that's case you as TB org.

You can also go to SPC and that's which is the El Paso County Medical Society's website and that's SPC TMZ.com.

Or you can go to youtube.com and then type in the El Paso position.

The nice thing is that this is aired live.

And then from there it is streaming in perpetuity.

So you guys will be able to be fined, found out by everybody.

And this honestly, this goes all over the world, the show.

So it's absolutely amazing.

I appreciate you both or all three of you for being here again.

We had Doctor Jose Marin Sanchez with us.

We had also Doctor Zaire Makoshi.

And then we had Doctor Wang who is on call.

So we need to get you out of here because I know you're answering texts right now.

Normally I would get mad at you, but no, I get it.

I'm Kathrin Berg, and this has been the El Paso physician.