Thank you, Dr. Lam. We'd like to invite Dr. Elias Rizk to the stage to finish out the conversation on lipoma and meningocelium. From a time point note, we have about 11 minutes of questions right now. So, we'll just try to keep on schedule. I was just going to go over some of the challenging cases or the cases that I've seen in the past couple of years in our practice. And when I was offered the title of the slide, I thought this was a little bit over the top since I'm still fairly young in this practice. And I thought it would be better titled as Lessons Learned During My Small Career in Pediatric Neurosurgery. So, the first case that we see a lot of old adults because, you know, our service is divided in a way that if you have a congenital anomaly, it goes to the Pediatric Neurosurgery Service. So, one of the cases a couple of years ago was a 33-year-old male, lipomyeloma hydrocephalus. And he had spinal cord detethering two times. It happened to be previously once as a child and a bit later in his middle 20s. And he's presenting with one-year progressive history of quadriceps weakness as he's trying to stand up. He needs to do like a semi-Gowers sign, tries to, you know, get some help standing up. And he's also having some ulcers on the feet on the calcaneus side and weakness in the dorsal implant reflection. His bladder function has always been off after the second surgery. And he's been in straight catheter cells for a while. And his sensation was up to the mid-shin area. And he's quite disappointed. And I didn't catch this on early on. And I encourage everybody to, you know, talk to their patients extensively. But he was quite despondent and disappointed. And one of his major concerns was inability to start a family with his wife due to lack of erections. So, that's the pathology as we see here. It's a terminal lipoma that's been operated on before. But when you look at the STIR sequences, you can start seeing that there's a hint of spinal syrinx that's starting to develop that was not present before. So, show of hands here, who would operate on this gentleman? So, I'm just gauging myself and my clinical intuition. So, we took him to the operating room in a NISA release. I sometimes put gel film, like you said, to creep that layer intact and try to prevent scarring, which almost never is seen on imaging post-op. But then two weeks later, he called the office. And he was bending over to pick something off the ground. And he heard a pop. And the first thing that he started to note was an enlarging, growing mass in the lumbar spine. And he sent me this picture from home, which is great. And you can see the pseudomeningosteal starting to develop. So, again, show of hands here, would anybody operate on this? Or would you guys, option two would be just watching it. Option one, operate. Okay, so a lot of people. Same thing, I did the, take him to the operating room. And within 24, we opened up and there was a clear defect in the fascial suture and the fascial layer. So we re-sutured that. But as, from my experience at least, the tissues are all wet in that location. And even if you try to dry as much as possible, there's always some accumulation that happens post. So within 24 hours of closing the fascial layer and making sure that everything's dry, he started to re-accumulate again. So we had to take him back to the operating room. And this time I took Dr. Diaz's advice. And I put a very large fascial drain above the fascia. It's a flat French drain. And kept it in until the superficial layer healed and the actual fluid was removed that was continuing to accumulate. So he did well with that process. At six months follow-up, his pain from pre-op in the lower lumbar region was better. But the main concern that he has was that the exit site where he had the drain come out, it's excruciating pain. He had no improvement of bladder function, no improvement in his sexual dysfunction. The ulcerations have resolved. But he now can have full strength in his quadriceps. And he gained one point on his dorsiflexion in the lower extremities. And that's his post-op MRI. And you can see part of the syrinx is resolving. So was it worth it? You know, even in his eyes, he didn't think it was worth it. But when we talked to him further and involved psychiatry, he turned out to be a major depressive disorder individual. And we had to put him on medications. So following treatment with antidepressants, he regained his job. He went back to playing his drum set, which he loved. And looking forward to starting a family. Case number two, 37-year-old police officer and has been having two-year history of low back pain. No bowel, bladder incontinence. No motor sensory dysfunction. And had a detethering attempt done at an outside hospital with no improvement. And she came in with this image. Fairly large terminal lipoma. Attempted to be resected, but still occupying the whole canal. And from Pang's data and the long-term retethering and amount of closure or removal of fat, it's shown that there's a correlation of decreasing the sinus of the lipoma and having symptoms post-operatively. Show of hands again. Would anybody operate on this lady? She had a prior operation with detethering. And now she presented with worsening back pain. That's the only thing that she had. No bladder, bowel dysfunction. We do, as Dr. Roberts has said, you know, pre-operative evaluation with urology. We have a very robust urology team. What was the interval between the first surgery and the second surgery? Two years ago. So I didn't do surgery. Six months of continuous PT. But she kept on calling the office. And nobody's helping her. Didn't have any response. So we referred her to chronic pain. You know, I don't know if it works or not. But sometimes getting the patient to get as much as alternative treatments as possible versus surgery is one of the options, especially if they're intact. She went through chronic pain and did a spinal cord stimulator trial. And that failed. Didn't help her pain. So what do you do next? Now you operate. Okay. Smart enough. So I operated and released as much as possible of the lipoma. There's still a little bit left here at the bottom edge. And I just closed the actual terminal spinal cord with small 6-0 proline sutures. So post-op, she needed immediate post-operative catheterization. And that resolved after six months and follow-up. Her pain. So the pevis pain that she had completely resolved. But I'm not sure if you encountered this. But a lot of the lumbar spine patients that we do tend to complain a lot about bilateral SI pain, SI joint pain. So we had to do another set of injections and PT. So one pain transferred to another type of pain. I'm not sure if we did something intraoperatively. But this is a new thing that we have to deal with. Everything else went okay with the previous surgery. And now it's a completely different beast that we have to deal with. So case number three. We do at Penn State fast-sequence MRIs for diagnosis of appendicitis. So on the images, one of the images, there was a hint of some intraspinal pathology. And the patient was referred to us to evaluate her further. And through the examination, completely normal child. Didn't even have appendicitis on her MRI examination. And had this MRI ordered. And you can see in the lower thoracic region, fatty mass. And you can see on the axial images, it's not dorsal. It's not terminal. It's like a combination dorsal and lateral lipoma. And then on the T2 images, there might be a hint of the dorsal root that's encasing into this mass. So normal child, what would you do? Show of hands. Operate. So yes, I did not operate. Just continue to watch this child. I've seen her for the past three years. I got another MRI at two years, and that's stable. And unless new changes happen neurologically, I would never touch this patient. And then I think this is the last case. It's a 14-year-old spinal cord. Not from me per se, but I've recently heard about this case. Very well-trained neurosurgeon. Did a fantastic job intraoperatively. He's done several of these before. And intraoperatively, everything went well. And post-op, the patient woke up and could not move the feet below the knees. Bladder dysfunction. And neuromonitoring intraop was completely normal. And I took this opportunity just to review this portion of the data about neuromonitoring and the lack of information in this field. And we should probably do a better job trying to have more of a prospective analysis of this from multiple institutions to try to understand the role of intraoperative neuromonitoring. And the reason behind this is a lot of times we're talking to people that are remote. Sometimes in our institution, we have the neurologists review the data remotely. So they're not in the OR. So they're going through a tech. So they don't have a good feedback of what we're doing in the operating room. You also have a lot of variables. You know, if you have water or CSF in the field, how cold is the solution? If there are any type of extra anesthetic. And the interpretation of the results, like I said, can be puzzling. And looking hard in the literature, you'd see that there's not much written about this except for this recent paper by Sela et al who looked at lipomyelosis. And out of his 47 patients, two had postoperative deficits that resolved after six months. But in all his patients, his SEPs, motor evoked potentials, and bulb of cavernosis reflex was intact. And so his false negative rate was 5%. But this doesn't really make anything better from that child who did that surgery and, you know, couldn't move his feet post-op. Thank you.

pediatric neurosurgery

lipoma

meningomyelocele

surgical interventions

post-operative outcomes