The Arab world consists of twenty-three countries, twelve of which are located in the west of Asia (MiddleEast) and the remaining eleven, in Africa. I will limit my talk to the practice of neurosurgery in the Asian Arabcountries. Neurosurgery in the African Arab countries will be considered in a separate talk given by Dr ElKhamlichi. With a total population of about 100 millions, the majority of the peoples in the Asian Middle Eastern countriesare Muslims and Arabic is the official language. Their geographic location, in the center of the world and at thecross roads of civilization, has had a great impact on their culture and development. As the lands in which threemajor religions (Judaism, Christianity, and Islam) originated, religion constitutes an important part of everyday life.Following World War II most of these countries became part of the British or French empires and only regained the independence in the second half of the last century. Thus, in many respects, they are young countries with an average age of around 50 years. Neurosurgery began to be practiced in the Middle Eastern Arabic countries in the second half of the last century, following the end of colonization and, although begun relatively late, development was rapid and internationally recognized standards were quickly achieved in many regions. Great efforts were made by senior neurosurgeons to initiate and advance neurosurgery services so that, at the present time modern neurosurgical centers maybe found in most areas. However, political instability, shortages and an uneven distribution of neurosurgeons aresome of the main problems facing neurosurgery in the Arabic countries. To secure the future of good neurosurgical practice and increase its accessibility we will need further development with increasing numbers of neurosurgeons,neurosurgical units, and training programs.

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A brief history of the development of neurosurgery in India is presented. References to neurosurgery can befound in the ancient Indian medical texts. Neurosurgery emerged as an independent speciality in India since the 1940's evolving with the independence of the country. The development of neurosurgery in various parts of thecountry is outlined. The Neurological Society of India is the national society for neuroscientists. Neurology India isthe official journal of the society. Pioneering contributions have been made by Indian neurosurgeons. The presentstate of neurosurgery and neurosurgical training in India has been enumerated.

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Around in 1990, it was very rare to meet neurosurgeons from Asia at the international meetings. A few senior professors could attend to it, but young neurosurgeons from Asia were impossible to attend to them because of their financial limitation. However, these young neurosurgeons treated so many poor patients in each country. They could not have chances to learn the neurosurgery update. Then, I did the negotiation with Japanese business companies, and I had the first seminar, neurosurgery update for young neurosurgeons in Asia at Nagoya, (my place) in 1993. Approximately 100 young neurosurgeons under the age of 45 gathered. We, hostside, provided all the air fee, accommodation, and food, et. al. to all the participants. Since that time, we have had 7 meetings in the last decade, and now this meeting is named as Asian CNS. So far, 1,918 young neurosurgeons participated in these meetings. In 2004, at the 7th meeting in Jakarta, we first had the participation from North Korea. Since 2004, WFNS kindly started its support to this meeting. Almost 10 years have passed. During this period, the Asian neurosurgery developed quickly and tremendously. Asia itself has developed in general. For further development of Asian neurosurgery, we began new educational courses. They are 1) cadaver dissection course of skull base, 2) Teleconference, 3) Exchange program among neurosurgeons and neuronurses, 4) Now, we are just beginning the new workshop course such as neuroendoscopic course, fiber dissection course and live surgery. The era for introduction of modern neurosurgery to Asia and grade up the quality of treatment has completed. We must aim the next step up which will be "Do accurate surgery" and "Do respect the patients' life more".

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Hemifacial spasm (HFS) caused by vertebral artery (VA) compression is a condition for which the surgical approach is often complicated. Among the 199 patients who received microvascular decompression by the authors, 45 patients (22.6%) had compression by VA or VA complexes (VA compression). In this review, patients with VA compression were analyzed. The VA compression amounted to 9.2 % of the whole right side patients with HFS and 32.4% of the left side respectively. HFS was caused by VA compression in 30.5% of men whereas this figure was 17.1% in women. For the patients whose onset of the disease was at an age younger than 45, VA compression was observed in 20.6% and for patients older than 46, VA compression was observed in 24.5% (not significant). Also, 22.7% of patients who had hypertension had VA compression, wherea 21.9% of patients without hypertension had VA compression. Thus, not all cases with VA compression were associated with atherosclerosis. As for surgery, the vertebral artery was transposed away from facial nerve using a prosthesis of Teflon^<[○!R]> tape and Teflon^<[○!R]> ball under auditory brainstem response monitoring. The prosthesis should not touch the facial nerve since this will lead to failure or recurrence. The vertebral artery can also be mobilized by attaching it to the dura of the petrous bone with glue. Full care should be taken not to injure or pull out perforating arteries from the VA or basilar artery when mobilizing these arteries.

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Vascular compressing syndromes in the posterior fossa include trigeminal neuralgia, hemifacial spasm and glossopharyngeal neuralgia. Arterial and/or venous compressions by SCA(superior cerebellar artery), AICA(anterior inferior cerebellar artery), PICA (posterior inferior cerebellar artery) and/or petrosal veins cause them. The surgical anatomy for microvascular decompression surgery is presented in detail. They include the "three's rule" in the cerebellopontine angle(C-P angle), the three different approaches to the 5th, 7th and 9th cranial nerves, the relationships between each cranial nerve and vessels, and anatomical characteristics of the supraolivary fossette.

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Recurrence of hemifacial spasm may occur due to inappropriate surgical techniques or due to a peculiar neurovascular anatomy around the facial nerve. The main causes of recurrence are as follows. 1.) adhesion compromized by a prosthesis inserted between the root exit zone (REZ) of the facial nerve and the offending artery, 2.) incomplete or insufficient replacement of the offending artery, a.) perforators of the offending vessel being short, b.) posterior fossa cavity being small and narrow, c.) an offending artery running between the 7th and 8th cranial nerves. Reexploration is indicated when recurrent symptoms progressively deteriorate and the physical condition of the patient is not problematic. Due to the author's study of patients with facial spasm who were operated and followed up for more than 5 years (5〜20 yrs) postoperatively, the average rate of recurrence was approximately 7.9% and the interval of recurrence was on average ca.4.8 years after MVD. A prosthesis should be inserted between the REZ and the offending artery, not between the artery and the brainstem, and transposition of the loop of the conflicting artery to the nearby dura mater is preferable. During reexploration, a very prudent technique should be used to preserve the cranial nerve functions, particularly the 8th cranial nerve, by monitoring Auditory Brain Stem Response with a knowledge of its critical limits (an elongation of the latency of the 5th wave <1.0 msec, a reduction of amplitude <40 %).

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Neurovascular decompression surgery is highly effective for the treatment of trigeminal neuralgia. However, there were some instances of uncured and recurrent cases. We performed repeat surgery for these cases. Among a total of 156 cases, 174 operations were performed. Complete pain relief was obtained in 86% of 142 initial operations. Repeat surgery was done in 14 operations among 16 uncured cases with complete relief in 92.9% of the cases and in 18 operations for 14 recurrent cases with complete relief of 83.3% of the patients. There was no arterial compression found in 50% of the uncured cases and 83.3% of recurrent cases. All cases had noted deformity or distortion of the trigeminal root. In cases with an enlarged suprameatal process, drilling of bone was added to visualize the distal part of the trigeminal nerve. Thickened arachnoid or granulations would increase the tethering force to the trigeminal root at the root entry zone and dissection around the root up to the Meckel's cave could give pain relief. Present study indicated repeat surgery combined with an untethering of the trigeminal root is effective for treatment of uncured and recurrent trigeminal neuralgia.

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