If anybody has any questions or comments, there's microphones in the center. Again, I want to thank all the international attendees for coming to the AANS in New Orleans. It's really a fantastic meeting, and you guys helped to make it even better. So I'll start with a question for Bernhard. Two questions, actually. In the U.S., it was anticipated that fenestrated screws for cement injection would have to go through a true FDA approval process. That never happened, actually, and they're now on the market, right, here in the U.S., too. Do you think that, I mean, those complications you showed were quite sobering. Do you think that maybe there needs to be some examination of that if there are actually deaths related to this? Microphone's right next to you, by the way. I would say so, yeah. I would say so, yeah. It's not as low as you think, depending on your indication. And if you use it in a high-risk patient, especially one with a cardiac problem, right heart failure prior to that, only a few drops of cement in their lungs will cause a symptomatic problem up to their death. So, yeah, there should be some, I mean, the prospective trial that we do, we will probably have a lot of data available how to avoid this. Some patients have a low-risk profile, and you can be very liberal, and others don't. And once that is figured out, there should be probably a maximum cement that should be injected. That means if you have so many screws, just reduce the number of screws that you augment versus not. Yeah. I'm going to follow that up with another question while Marjorie's setting up. You know, we had an experience in the United States with Norian, which ended up, it's almost like a crazy soap opera, and actually some of the company people who are selling the syntheses, you know, went to jail over this. And this was a cement that just caused a whole vascular system to coagulate. In Europe, in Germany, are you looking at other cements that are maybe more congenial to that environment, if you get some embolism, that it's safe for something besides PMMA, right, because that's what you're showing is PMMA, right? Yeah. Well, there are different forms of cement. I'm not a specialist on what is superior to what. But the one we are using now, we are using no longer. I don't know if the new one will be better, and I don't know if someone really is into that. That's methyl methacrylate. You're using forms of methyl methacrylate, right? Yeah. They're all forms of that, right? Yeah. Okay. Yes, please. Hi. My question is to Claudio's form. Very, very interesting and very exciting work that's going on regarding regeneration of discs and replacements, et cetera. My concern, and I'd like your comment on it, was that the whole focus seems to be on the stuff that's between the vertebral body. And there's obviously a lot that goes on. Does the patient stop smoking or doesn't smoke? Does he put on weight? Does he exercise? What does he do to the muscle tone? Because we know you take two patients, identical disc surgeries, identical symptoms, and one looks after his back, the other doesn't. One walks regularly. One consistently drives. One goes back to motorbike riding, et cetera, et cetera. So there's the whole halo around the actual structures between the two vertebral bodies. That seems to be also the problem. And that may be the result or the reason why we get so much recurrences in one subset of patients and not in the other. I'd like your comments on that. You're right about the importance of those factors. Actually, we just published two papers. One is going to be published soon on smoking in very young disc patients below 20, because there are a lot of them in Europe that smoke at a very young age. And that is a dramatic risk factor for reherniation if you smoke at a young age, interestingly enough. And if you do sports before having the herniation, your outcome is much better than if you have not done sports before. So we actually could show this makes a huge difference. But this is something we cannot address right now. I think you're right that those patients that do take care of their back, muscles, et cetera, et cetera, then they will be less likely to have that severe degeneration. But we don't even get that far yet. We just say when there is degeneration, what can we do about it? But you're probably also right, and we're looking at this for the studies as well, because some of those conocyte trial patients were smoking and some were not. And maybe we'll see something there, but we don't know yet. So I was going to ask another question, Dr. Thomae, as well. It's my understanding that Barricade was not approved in the U.S. because of some concern over the lytic lesions. And so another question, you mentioned that in some new literature that's come out. And also, have you paired an annular closure device with your nucleus replacement? Two questions. One, to the FDA, it's currently still under investigation. The FDA is not involved in that FDA investigation or whatever that's going on there. But it's currently, they're currently, those are the concerns about the end plate changes. And that's something that we as an investigators group, that's why we put so much emphasis on this, because we want to understand this problem. That's why we actually have, I think, five publications ready now. Three have been published and two are more to come to really understand this issue. As I said, as far as I can say from an investigator standpoint, it really doesn't seem to have a negative impact clinically, but obviously we don't know whether this could theoretically have an impact 10 years down the road. So this is absolutely an issue. It seems to be that it's an early phenomenon that actually improves over time. But again, we are only now three years out. So this is something we have to look for, quite obvious. And concerning the combination, that would be the ideal way. But, I mean, we would take it step by step. First, really see whether the end of a closure device does what we expect it to do. And then we would start potential with nucleus augmentation to combine the two. But we haven't done that yet clinically, no. When you have a question or comment, please, if you could give us your name and the nation you're from, the country of origin, please, here. Jacob Young, Charlottesville, Virginia. Jacob Young. I have a related question to the last question, actually. You know, we see many 70- and 80-year-old patients with completely collapsed discs, terrible degrees of scoliosis. You have very little pain related to that. I'm sorry, can you come closer to the mic? Hello? Thanks. All right. So it's related to the last question. We see a lot of patients in their 70s and 80s with terrible degrees of disc degeneration, scoliosis, disc face collapse, and some of them even with terrible foraminal stenosis that don't seem to have pain. I have many cases of congenital spondylolisthesis with flattened nerve roots that have no pain until a certain age. So they must have lived many years without discomfort. And I'm wondering if the emphasis on restoring the, you know, the normal anatomy and height, and this is some other aspect of why people continue to have pain or develop pain in the first place. For example, so many of the patients that I see in America have pain related to job loss or dysfunctional family lives or smoking, as you say, and we know smoking is a comorbidity to life distress. And I'm wondering how much attention Europe or your country puts into that. That's a difficult question. Probably not enough. We all know these disappearances between clinical and radiological images and whether something, I think it's mainly a matter of whether you do have inflammation, whatever inflammation there or not. We don't understand why some patients have inflammation around their disc and some don't. But I absolutely agree with all your factors. We're actually looking into the psychological factors. We've done a study years ago looking at those conflicts at the job and the family, and I thought this was not going to have any impact. And the study, we did 100 patients, and those that had a poor outcome, the psychological expert told before in all of those that they had a conflict, and those were the ones that had a poor outcome. And I think there was 15 of those 100 that had a poor outcome or not a perfect outcome, all had conflicts. In the other group, only five of 90. So this seems to be important, but this is nothing we can address right now. But it's a concern, but we don't have a good solution for it either. I don't think we are any better than you in the U.S. looking at these factors. Yes, in the back. I'm Dr. Dushyant. I come from north of India. This is regarding port spine. One comment, it's no longer a disease of the poor. You find it in affluent families too. And secondly, I just want to take your take on that. Many times with whatever investigations we might do, nothing is concluded. So four to six weeks of antitubercular drugs are put on. So what's your take on that? Whatever you might do, you're not reaching the diagnosis to confirm tuberculosis. So many times we put the patients on trial for a six-week ATD trial. Well, it's an important question. It's not always easy to have diagnosis. And it's not always easy to put patients under drugs. And we know that we need at least nine months of antituberculosis. So clinical and radiological assessments will lead us to decide if the patient needs this treatment or should we wait. To put a patient under drugs for six to eight weeks and see what's happened, I don't know if we will be able to stop drugs after two months. This is the second question. So it's a presumptive agreement that we should look for to decide if we put patients under drugs or not. And there wasn't a second question? I think it was more of a comment, I think. A comment, yes. Actually, I have a question. I was wondering if you could speak to what kind of bone graft you're typically using. Are you usually using rib or autologous graft? And our infectious disease folks are always trying to get us to take out hardware if there's a prolonged infection. Do you have experience with that? Are you able to just leave the hardware in? Are you having to remove it? Well, I will start with the second question in tuberculosis. In this series, I've done it when I was in the department of Professor Khamilishi in Rabat. And all these patients where we put osteosynthesis, there was no problem with material, with screws or with rods. And basic science studies show that we can do osteosynthesis without any problem in tuberculosis because the progression of the infection is very low, and this allows us to heal the patient without any problem. For the second question, it's about the bone graft. When we do thoracotomy, for example, we use rib. Sometimes for large corpectomy, we can use fibula. So you're using allograft? Just allograft. Or the patient's fibula? Just autograft. Just autograft. Autograft. Autograft, yes. So next, Marjorie is going to present a case to us. And we have a panel of experts here from Eastern Europe, Western Europe, North Africa. So maybe we can get a feel for how a case would be managed in different parts of the world here. Marjorie? All right. So these are some cases that were put together by Hesham Solomon, who's one of our newer faculty members. So this is a 68-year-old woman with a myeloma and neck pain. She has myelopathic on exam and has their means. So some of the questions would be, if we look at the films here, you know, what kind of approach would you take? Would you put the person in traction, do 360, or add a verteroplasty to this? So here are the films again. So anyone want to take a stab at it or just give us your thoughts? Professor Dimitriades, why don't you give us your thoughts? Thank you. So do we assume there's involvement of C2 posteriorly or not? Yes. So my preferred approach would be to go from the back first, get some stabilization from occiput down to mid-cervical spine, and then proceed to an anterior decompression with corpectomy, stabilization. Would you try putting the person in traction? Never. No. So anybody else, would you put them in traction? No. No? No. Okay. I would not include the occiput. Me either. C1 to a couple of pedicle screws and 4, 5 maybe from the back first and then do corpectomy in the second stage. I would probably even think about, depending on how good the construct is from the back, I mean, you have to use monitoring for this when you reposition the patient, obviously, because positioning will be somewhat challenging. If I get a good posterior construct, I'd probably just radiate her because she's going to recalcify quite rapidly, and you may not even need anterior corpectomy in a myeloma. So you would do posterior only first, and then Bernhard, you say you'd do a corpectomy after the posterior fixation, right? I would do posterior, see what I get. If I could get the reposition, then I would decide whether I'd do a second stage. Most probably I would, then put in some form of replacement, but not necessarily. I mean, you can do it either way. Any special approach to get to C2? You mean from the front? From the front, yeah. Yeah, but transcervical usually. Standard. That's good enough. You think you'll get there just fine. Yeah, yeah. I was just going to ask if C2 posteriorly is involved, is C1 enough? Yeah, certainly. Hopefully, yeah. Well, you probably would have to see the whole CT scan to really make that call, and that's what I mean. That depends on how good your construct will be in the back, whether I think you would need to go in front or not, but that's hard to say from those films. Would anybody first try to just irradiate this and see if there's any improvement? Why? Everybody here would operate on this patient? Sure. Everybody? How about putting cement in there? Would anybody do that? No? Okay. How about the audience? Any comments from the audience? Do you do this from the back or front? No? Show of hands? Anterior? How about posterior? And how about both? It's about even. Yeah. All right. Okay, so this is a 79. What did you do? What did you do? Oh, this is Hesham's study. This is Hesham's cases, so he did both. So he did both. That's what he did. Back front or front back, do you think? I don't actually know. I think he did front back. Okay. Back front probably, right? I don't know. All right, this is the next one. So 79-year-old woman with neck pain and myelopathy. So she's got a history of a fall and a fracture 25 years ago. And this is her scan. So how about traction for her? No? All right, and then how about approach? Thoughts? Is there instability of what's there at the C1, C2 junction? I can't really tell. Is that unstable? Do we have flexion extension films, or is that okay? So that was okay. I don't have the flexion extension films to show you. I don't think that's a problem. So, Professor Said, you're in Algeria, right? What do you do for this in Algeria? We must complete with CT scan to see the anterior completion by the ligamentus or osteofetus. And also we can do a somatotomy with graft. Anterior approach. Anterior approach. The completion is anteriorly. And you cannot operate it without a CT scan. So you had mentioned looking at the, oh, sorry. After that, if the evolution is not good, you can secondly operate it by posterior at the C1, C2. I'm sorry. So you would do a standalone anterior and then wait and see how the patient did? Anterior with fixation, with the graft and fixation. ACDF. Yeah. ACDF, okay. Dr. Qureshi from Kenya again. We're doing exactly what we teach our medical students not to do. Don't treat x-rays. She's a 79-year-old. We don't know what her cardiac status is. I don't know what her lung, what her pathology is, whether she's going to take that kind of, even if it's a two-hour surgery, what her ability to take that anesthesia is. So I don't think we should go on straight by saying this is what I would do. I think the younger folk in the audience will say, hey, in the grand rounds you tell us don't treat x-rays, treat the patient, and here you are going straight for a 79-year-old doing big stuff. So then the next question is, she's fit for surgery. She's actually physically or biologically a 60-, 65-year-old. The pathology seems to be at C3-4 mainly because even though she's got the odontoid tip displaced there, but I think the C3-4 is where the problem is. Clinically, if that's where her signs are, then one would just target the C3-4. You wouldn't go to the others. It really depends on what her clinical findings are. So you bring up a good point. So we're sort of throwing these cases out more for discussion than sort of actual specific patient management. So, I mean, you could add if there's osteoporosis, how would that change your approach and things like that. But so what would, you would do a laminectomy at C3-4, is that what you're thinking? So you would do an ACDF at C3-4, okay. Perfect. Yeah, I mean, she had myelopathy, so we're not treating a patient without any symptoms. And I think that was exactly what he said. He would do an ACDF on C3-4, because it's most probably the, I don't think this is major surgery, not for a 79-year-old. Most people I see nowadays, I mean, are at that age range. So I could stop most of my practice with DGEN if I say 79 is old. What if she has severe osteoporosis? Would that change anything? Well, actually, for me, it would, I don't think I would do this from the front. We had a few cases exactly in that group that didn't do well from the front. And the 79-year-old, I'm still not sure. I think she's had a Jefferson fracture back then. That's what it looks like on the images. So I'm really still a bit concerned about the C1 or whatever. But if it comes down that this is okay, actually I would probably nowadays do a small posterior fixation and decompression. I think it's going to be easier for her. What kind? Just laminectomy there and screws from either three to four if that's short enough. I'm not that sure about five, six as well. So you may even go for a longer something here. How about in England? What do you do in England? It's true that in England people are more conservative and they don't treat people who are older than their parents. But 79 is young enough. I think in this case in particular, a C3-4 is not a particularly difficult operation. But it seems that you've chosen this because it's anterior and posterior compression plus instability at C3-4. My preference would be to go from the back because it will give you a wider decompression and will also give you the chance to address instability. Maybe potentially doing flexion extension x-rays, assessing the C2, C1 complex. And as Claudia said, maybe going down. Although the problem is C3-4. Another reason to go from the back is the fact that elderly people do have a higher incidence of dysphagia. And that's something we need to take into account. According to the frailty assessment of the patient. Yeah. Particularly at C3-4, right? The higher up you go, the more dysphagia you see in old ladies. It's a woman? Yeah. I mean, it's a concern. You know, this is a great case, Marjorie. I think you could even have a discussion on how many levels. What do you think in America, what percentage of surgeons, Marjorie, do you think in America would do more than one level of surgery front or back on this case? An honest assessment. Not us. I'm not talking about us. I'm talking about if you just take all comers. You know, I think you would get a number of people looking, getting scoliosis films. Looking more at that kyphosis that she's got. I don't think many people would do a laminoplasty. Although that was one of the options for the recent study that Zoe has just closed enrollment on. Looking at anterior versus posterior surgery for this. But certainly, you know, if you look at the AO data, that laminoplasty has been done a lot more in other countries. How about you guys? Laminoplasty? Well, quite a, I would say 20% of neurosurgeons I know or spine surgeons I know use laminoplasty. I've never used it for leeching cases because I don't believe in its advantage. So if I come from the back, I do wide laminectomies and do instrumentation. The only instance I use laminoplasty in young children where I take out intramedullary tumors or something like that. How about anybody else? Laminoplasty? No, only for children. Same here, I've used it in the past and I've completely abandoned it. I don't think it has any advantage over laminectomies. I actually went back to do laminectomies, pure laminectomies, those muscle sparing laminectomies for old patients. You can do them very minimally invasively, like a skip laminectomy or whatever you find in literature. And they are very good even without instrumentation in the right patient, in those that don't show instability, have nice lordosis and are old. Those are usually good cases. And I don't see, and the others where I would potentially, where I thought about laminoplasty in the past, it hasn't worked either. They have a lot of neck pain or they get kyphotic anyway. So it hasn't worked for me. But I know that a lot of people, maybe they do it better than I do. Yeah, so maybe if there are any Asian colleagues from East Asia, in this particular case, is the spondylolisthesis and the amount of loss of lordosis an absolute contraindication to laminoplasty? Anybody have any comments on that? I know that some people would do a laminoplasty on this because of those elements, you worry about that. But I'm sure that some people would do a laminoplasty on this in Asia. But we should be quite clear, this is a contraindication to laminoplasty. Relative contraindication, relative. Everything's relative on this patient, right? Ma, the essence of laminoplasty or dorsal decompression is the fact that the spinal cord can go backwards, right? And it's impossible in this case if you leave it in a kyphosis. So you don't get a proper decompression. I would have my doubts. Well, yeah, I mean, I think the, and I'm not arguing for it. I wouldn't do a laminoplasty either. But I think the argument that people would make for this case is because of the instability, we know laminoplasty is a kyphosing procedure, but it also restricts motion, right? We know that it's somewhere between a fusion and a laminectomy. So I'm sure that there are people that would look at this and go, yeah, that's an acceptable case. I wouldn't do it, but I think that there would be people that would do that, right? Yeah. How about the audience? Would anybody? Anybody? No? Laminoplasty, maybe? No? No takers. All right. Solution? Let's see. Oh, wow, that is a big surgery, right? Yeah. Yeah. So I was going to say, Marjorie, that I think in the U.S., if you just take all comers, and I'm not saying it's right or wrong, if I saw this case being done in America, I would say probably 30 plus percent of people are going to go multi-level on this for whatever reason, good or bad, but I think they're going to do it. Yeah. That's a big surgery. That's a big surgery. That's a really big surgery. Yeah. So here, the rationale here, I'm assuming, I know you don't have insight, is because of the old Jefferson fracture, they're trying to treat something that pre-existed or? Yeah, I think so. Interesting. You know, the other question is what happens if you get in there and you start like doing your posterior fusion and then your screws just, you know, they're just loose. You're just going to just extend to keep going or? So you could end up looking like that. One of these is pedicle screws. I mean, usually, even in osteoporotic patients, they have quite a bit. Hutchison. Microphone. Bernard, microphone. Oh, sorry. If I had doubts, then I would use pedicle screws, and that would probably resolve all the problems related to osteoporosis. All right. I think we have time for one more. So this is a 16-year-old with Down syndrome, progressive quadriplegia, so he's also very symptomatic. He's young, otherwise healthy. So this is his CT and his MR. So, all right. I'm going to ask again. Traction, anybody? All right. This one might go for traction. This one, you want to? Because he's 16 or a couple days? Three days of traction and see how it looks afterwards. How about the audience? Would anybody put this person in traction? Please, yeah, come up to the microphone so we can hear you. For the gentleman who put his hand up, yeah? If you do the traction, would you consider a short, sharp course of steroids? No? All right. Because I'm tempted to go posteriorly, really, decompress that posteriorly, and stabilize it rather than go from the front. Do you typically give steroids when you do that? Come again? Do you typically use steroids for this? With that kind of malamutation, I do tend to, yes. But I don't know how many of the audience do that. It just makes me feel better, I think, because there isn't evidence one way or the other, as far as I'm aware. You mean preoperative or intraoperative steroids? Intra and post-op. Oh, post-op. So, Decadron or Solumetrol? The Solumetrol. Solumetrol. Marjorie, so I read the literature, and it seems like in China and Korea and Japan, they claim that they can always reduce this from the back. Like, you see the papers, 100 cases, everybody reduced and all that. How do you guys assess that ahead of time? You know, can you predict that? I mean, do you guys know when you're going to be able to get a reduction? Because I've been frustrated by it, personally. No, to be honest, this is a difficult case, mainly because it's not that much an upward motion of the odontoid. The odontoid is not even that high up. It's more far back, and that seems like because there's a lot of pannas in the front. So, I can't really judge this without any flexion extension films, or sometimes in those, even if they're young. We tend to do even a CT scan in flexion extension to really see exactly how much they move, because then I can tell whether I can do it only from the front. And I would be truly worried here. I would always start from the back. Sorry, I couldn't do it from the back. I would always start from the back. But this may even be a case where you don't get the odontoid that much more forward by just a posterior approach. Because this is different to those that just go upwards, and you can distract them in the back. Yeah, how about in England? Still distraction. Do you have a comment on that? Thank you, Mike. I'll go from the back, do a C1, C2 fixation, and laminectomy. The, you're right, the Asian reports of putting a cage between the C1 and C2 joint and distracting it are very exciting, but in my hands it doesn't always work. And in a 16-year-old, I'm not sure I would be able to achieve that, but I would assess that. Rather in a 16-year-old than in a 60 or 76, the issue why you can't do it in the older is because you violate the facets. But in this guy, you probably could always give it a try. Distraction between C1 and C2. Marjorie, to the point of the gentleman from Nairobi, so how functional is he? What kind of, is he a high-functioning Down syndrome? Is he wheelchair-bound? Tell us more about the social and congenital nature of this patient. Well, this is Solomon's case, so I would have to speculate. Oh, I'm sorry, this is not your case. This is not my case. Well, maybe I can ask the audience then. Does that, yeah, please. Does that weigh into your decision with a Down's case like this? There's a lot of core compression, but is there a consideration of, let's say, a very low-functioning Down's patient? Do you say, well, you know, maybe this is not worth it from a lot of perspectives? Yeah, please, go ahead. Adil Chagla from Bombay. We'd go from the back. We do a decompression, including a little bit of the foramen magnum. We open up the joint space. When you open up the joint space, you get a little bit of bone as well from the procedure. And if you open up the joint space, you'll know how much you can manipulate that joint. And with CIAM or without, or even with just an X-ray, a lateral X-ray, we'll be able to know whether we've been able to achieve the reduction on the table, and then instrument from behind. Lateral mass with particles. Bernhard, you were gonna say something. I mean, you nodded, you shook your head, like it doesn't matter about the functional status you're gonna do in this case. Yeah, yeah, I mean, you need- Give me the explanation on that. Let's have a little debate on that, because I think it, to me, if the patient's low-functioning, I'm thinking, wow, you know, I mean, what good am I gonna do here? This is fairly high risk, as Claudio said. There's a risk this patient's gonna be even worse when we're done. What do you think? Tell me what your thoughts are. Well, I, what is high-functioning, what is low-functioning? This is in the eye of the beholder, and the parent, and the patient himself. So a Down syndrome patient, even if he's low-functioning, that wouldn't go into my decision-making at all, at all. So he's becoming quadriplegic if you don't do anything. So where's the point in not giving him the treatment that he deserves as much as I would, or anybody else in the room? So this has nothing to do, for me, within my decision-making. I agree. In our social environment, this would not be a discussion. The parents wouldn't even think about not doing something now. Let me just put it another way to make it a little more controversial. What if it's an institutionalized, wheelchair-bound Down syndrome where there are no parents, right? And the discussion, and maybe there's a ward of the state, right, there's an assigned person who can give consent. Does that change it, or do you still treat it the same? Not at all. Given my German background, it doesn't change at all. How about in, I wanna hear from the gentleman from Morocco and Algeria. Is there any difference in your country when you look at that? And this is not a, I'm not trying to indict anybody. I'm just curious to hear the perspective, because that's partly cultural, right? In Croatia, too. In Croatia, I'm seeing, Croatia, too, yes. The imaging is a real anterior compression. So, and we have myelomalacia. Myelomalacia, yes. Myelomalacia. After traction, if addiction, myelomalacia, fixation, C1, C2. And if there is not addiction, if it is take this, maybe the compression and the fixation with the occipital. To the occiput, you go to the occiput, okay. But C1, C2. It's my opinion. How about in Croatia? Let's hear from Croatia. Yes. I would agree with Dr. Seif. No differences, considering the approaches. And considering social aspects, considering social aspects, I agree with you. It doesn't matter. It is not, we are not, we are doctors, and not sociologists, and I believe that we do operate without any social restrictions. And the same consideration would go for a 90-year-old, for example. Nine? 90-year-old. 90. Yeah, okay. No, that's interesting to hear from Europe. Yeah. See, it's a difficult discussion, especially within Europe. This is a philosophical discussion, especially within Europe, especially within my country. Given our history, I'm very reluctant to judge what is worth being treated or not. And if I'm in doubt, then I'm always on the side that I would treat the patient. Because I'm not the judge for life, or what is worth living or not. Yeah. So you'd rather have a error of co-mission than omission. Exactly. Because that's the cultural context as opposed to. So it's interesting, because in America, I think we're a little bit to the other, not completely the other side, but we fear errors of co-mission, which is that, just like the gentleman from Nairobi said, you operate on someone and you hurt them, and why did you do that, right? And there is that piece, too, and not that we're rationing care or anything like that. I think every surgeon has to find their place in this, and there's a cultural context for this, which is really interesting. So anybody else have a comment on this case? This is a very interesting case. Or how about in Morocco? Yes. Yes. We are a physician. We don't have the right to decide if the patients will, if we do surgery or not. I explained. He will go to tetraplegia, so I should do something. And if he has Down syndrome, it doesn't change anything in our practice and our culture. People in Morocco trust so much doctors. You can explain to them what is happening, and they tell you, you are in control. And in this situation, you can't let down the patient. And for us, we'll do a posterior approach with the compression and the fixation. So we sort of stacked the deck here a little bit, saying this was progressive quadriplegics. So what if it was severe quadriplegics that had been going on for at least three months, or six months or something? Same thing? No change? Interesting. Okay, how about the audience? Any differences in your countries? I think I see Nabil back there. Nabil, what do you think? Would you operate on this? Or are there any considerations for somebody who is quadriplegic for like six months? Sorry to put you on the spot. Sorry I wasn't on the phone. But this patient has Down syndrome, right? And I worry with the myelomalacia to do any dynamic movements in this patient, just because the patient is already clinically getting worse and there is evidence of myelomalacia. So I wouldn't attempt to do that. And I think based upon the whole picture, I would want to operate and I would start from behind. And try to see if I can actually do a posterior decompression and instrumented fusion. And you have a lot of experience in different countries as well and with your teaching across Europe. Do you see differences in the different countries that you've been in? I think with these rare cases, considering we have audience, we have faculty here from instance from Northern Africa, I think they follow the French philosophy. And when you look at the Anglo-Saxons philosophy, we are not that different from each other. There are some differences like with laminoplasty and so on. But I think with this case, I think everybody here agrees that there are not so many choices. I think the interesting thing, would you go from interior or would you just do this from behind? And I've seen, and I'm not as experienced as the panel up at front and I have high respect to them, but I've seen a lot of patients with this kind of picture, but they're still neurologically intact. So I wonder if there is a need to go from interior and maybe just doing it from behind with a bit of decompression and instrumentation would actually cure this patient or just stabilize this patient. I would be curious if anybody in the faculty agrees with that. All, I think, all agree. So what did you do, Marjorie? What did they do? Let's see, what's next? Traction. All right, posterior, yeah. To the occiput, yeah, okay. That's the last case you have? Excellent, I wanna thank all the speakers for staying on time. It's really great discussion. We have a beverage break and then the second session Jacques-Marco's gonna be leading will be on cerebrovascular. So please come back after you get some coffee or soda. Thank you, guys. Thank you.

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