3 LEVEL CERVICAL FUSION

3 level cervical fusion using bone graft from the Iliac crest.

Preoperative x-rays shows cervical spondylosis and osteophytes at C4/C5 and C5/C6.

MRI scan shows spinal cord compression at C4/C5, C5/C6 and C6/C7. There is also significant myelomalacia at the 3 levels. So an operation was advised and carried out.





 







The post operative image show the decompression and fusion.

Medical tourism for back pain

Mr Glory Chinda turned out to be one of the most interesting patients I have ever had. This gentleman was seen recently and underwent surgical intervention for severe back and left leg pains. The 39 year old father of four came from PortHarcourt to Abuja. This is like internal medical tourism in Nigeria. He said he had read an article about a woman with back pains and the description was exactly like his symptoms. In other words, the pain in his left leg was like electric shocks, akin to a million pins being stuck in his leg. The leg pain is what we call sciatica.

He presented with electric pains in the whole of the left leg due to a disc prolapsed at L4/L5 causing significant narrowing of the spinal canal through which all his nerves travel. This had been ongoing for 6 months and interfering with his life. Sleeping, walking, sitting, standing and work were all affected by unrelenting pain in the leg. Even pain killers only lasted a few hours in ameliorating the pain.

We reviewed the MRI scans performed at Lifebridge Diagnostic Centre in Garki. He had a huge disc prolapse which required surgical intervention. The operation was performed successfully at Garki Hospital, Abuja and he recovered well. 

Post surgery care and recovery

He noticed immediate improvement in the back and leg pains. His walking ability and comfort had also improved significantly. The specific instructions for similar patients are that they need to take things easy for about 8 weeks following the operation. This is a major spine operation though with good early recovery. However, disc prolapses can recur so patients need to take things easy and allow healing to be completed before undertaking serious work again. 

Also, physiotherapy and back care instructions are important. No heavy lifting and no sitting for prolonged periods. In fact, one surgeon tells his patients not lift anything heavier than a cup of tea.

Most patients are anxious to return to work but this should be phased. I often caution against an early return to active duty. When they return to work, it should be to undertake light duties for a few hours a day and no more. Then a reassessment is done before commencement of full duty requirements.

Medical tourism

The diagnosis and treatment in this case was carried out within 24 hours. This is much less than the time it takes to get a visa and travel hundreds of miles to another country. It means that he obtained relief from his pains in a short time and so can start the healing process early. There are some illnesses such as spinal cord injury and nerve compression requiring immediate medical attention that cannot wait for the flight to other countries. Also post operative follow up and care is assured locally.

The key issues are that medical tourism is eroding the fabric of our own health services and further depleting the nation of medical facilities and expertise. It demoralises local medical practitioners and increases the brain drain. It reduces training of medical students, further creating substandard and poorly trained doctors to look after us all in the future. It simply creates a vicious circle we must break free of.

The colossal sum of money spent abroad could be used to equip more local hospitals in Nigeria to perform even more in delivering care. We need to develop our local hospitals and help prepare them to be able to help when it really matters. Supporting the local hospitals and ensuring that it has both personnel and equipment may be the difference between life and death. Many patients have gone to other countries and return dead or injured despite colossal sums of money spent.

Spine: Fixed in Abuja

There are several good quality diagnostic centres in Abuja. Medicaid, King’s Care Hospital, Primus International Hospital, and Lifebridge Diagnostic Centre are all well equipped with CT and MRI for diagnosis of spinal conditions.

The operations on the spine can also be conveniently carried out at many hospitals including the National Hospital, Garki Hospital, University of Abuja Teaching Hospital, Wellington Neurosurgery and Asokoro General Hospital. This is because there are trained surgeons in Abuja offering specialised spine care with a full surgical team backup and all the necessary equipment. Neck and back pains can be conveniently managed in Abuja and Abuja is set to be the destination for Nigerians with spine trauma and degenerative diseases.

Spine: Fixed in Nigeria

Many cases of effective and efficient management of cases of spine problems abound in Nigeria. Patients do not need to continue to troop out to other countries in search of quality of care. At least for spine, we can now boast of the capability to manage most cases of spine problems to very high standards in Nigeria. There are surgeons in Sokoto, Enugu, Abuja, Lagos and Ibadan making huge strides in providing quality care.

As usual, lack of information on what is available locally impairs access to care. You need to know that the future is bright, for patients with spine problems. Spine problems should no longer be a reason to travel out of Nigeria.

This article has been published with the kind permission of Mr Glory Chinda.

Pictures and legend

x-rays of normal lumbar spine, and the other two of a patient who had a fixation with pedicle screws and rods.

Lumbar Spondylosis treated with pedicle screw fixation

Lumbar Spondylosis

Lumbar is the medical term for the lower back. Spondylosis is again the term referring to degenerative arthritis of the joints between the bones. Therefore, lumbar spondylosis is arthritis of the back. The back supports the body and helps keep us upright. It is therefore affected by the weight of the body especially when standing, sitting and walking. Pain in the back can radiate to the hips, the legs and the private parts. With pressure on the nerves, it can lead to numbness in the legs and weakness causing difficulty in walking. It can be so bad as to cause problems with passing urine and stool. It can also affect sexual function.

The causes of common back pain are as follows:

·        Poor posture

·        Improper lifting techniques

·        Back injury such as muscle sprains

·        Bone and muscle disease

·        Stress, anxiety and depression

·        Degenerative conditions such as osteoporosis and arthritis

Treatment of Lumbar Spondylosis

·         Resting: 1-2 days of bed rest is advisable and most pains will settle. Sleeping on a firm mattress is also good.

·         Over the counter drugs such as paracetamol and aspirin taken every 4-6 hours can also help reduce the pains.

·         Weight reduction, in people who are over-weight.

·          Physical therapy by a trained physiotherapist.

Life style changes

·         Stop smoking.

·         Stop alcohol.

·         Lose weight.

·         Exercise.

Drug treatment

·         Paracetamol

·         Aspirin

·         Ibuprofen

·         Voltarol or Diclofenac

·         Tramadol

·     Steroids like PREDNISOLONE are NOT RECOMMENDED TREATMENT for back or neck pains.

Surgery

Operations can be designed especially for each patient depending on their particular symptoms, signs and MRI. The operation is done to address the particular problem, be it, back pain, leg pain or both. Pedicle screw fixation is for back pains due to spinal instability. 

The following are images of a patient who had had the screws inserted.

 

Anterior Cervical Discectomy and Fusion (ACDF)

Cervical Spondylosis

Cervical is the medical term for neck. Spondylosis is a term referring to degenerative arthritis of the joints between the bones. Therefore cervical spondylosis is arthritis of the neck. The neck supports the head and when the neck is injured, you can feel like the ‘weight of the world is on your shoulders’. It can cause pain in the neck, radiating into the head, pain shooting down the arms and pain down the spine. It can lead to pressure on the nerves or the spinal cord. This can then cause numbness in the hands, legs and difficulty with walking. It can be so bad as to make a patient completely disabled.

The causes of common neck pains are as follows

·         Poor posture at home or at work leading to neck strain and muscle spasms

·         Cradling the phone between your neck and shoulder (without using your hand)

·         Neck injuries such as whiplash

·         Lying on your stomach to read for long periods

·         Degenerative diseases causing disc prolapse and arthritis

Treatment

·        Prevention of neck problems by avoiding the common causes as above

·        Neck exercises and physiotherapy (including massage and use of cervical collars) 

·        Using drugs as prescribed by the doctor (paracetamol and anti-inflammatory drugs)

And finally surgery

Surgery for cervical spondylosis can be either simple or complex. Simple operation includes simple epidural or nerve root injection performed carefully in theatre. This must be done under x-ray guidance to avoid the injection going into either the spinal cord or even the arteries in the neck.

The operation often prescribed is called an ANTERIOR CERVICAL DISCECTOMY. This can be done with or without fusion. Fusion entails putting either a bone graft from the person or an artificial implant in the space between the bones (after removing the disc, called a discectomy). This bone or implant allow the bones to fuse together in a solid manner within about 2-3 months. Sometimes doctors supplement the fusion and enhance it by putting a cervical plate and screws on the bones. This makes the neck solid and fixed immediately while waiting for the fusion to occur.

Below is a picture of a patient who has undergone the operation. This person has undergone an ADCF with iliac graft and a plate. The plate and screws are over the 4th and 5th bones in the neck. There are seven bones in the neck, of course.