So you need a back operation?

Patients who have severe back and leg pains due to arthritis of the spine may be offered back operation. Spine operations are more commonly used to treat lower back pain resulting from a damaged or degenerate intervertebral disc (the shock absorber between the bones), or spondylolisthesis (slip of one bone on the other). The goal here is to stabilise the spine so that pain (and sometimes deformity) is reduced. Operations are also used to treat lower leg pain resulting from pressure on a nerve or nerves in the back. The goal then is to free the nerves from pressure and so stop pain, numbness and weakness in the legs.

Surgery is usually recommended when all reasonable conservative measures (pain medications, nerve injections, physical therapies, braces etc.) have failed. It is often the last resort unless there are special circumstances like severe nerve injury that makes it the number one priority. Operations on the spine can be performed from the back or the front. We more commonly do it from the back. Operations from the front entails going through the abdomen and may be required in some special circumstances. More often than not, it is combined with a second operation from the back as well.

The goals:

Reduction of back pain

Stabilisation of an unstable spine

Reduction in amount of drugs used for pain

Prevention of deterioration in your condition

Improved lower back and leg function

Improved work, walking and recreational capacity

Improved quality of life

There are risks in back surgery as with any operation. The chance of a minor complication is around 4 or 5%, and the risk of a major complication is 2 or 3%. Generally, surgery is fairly safe and major complications are uncommon. Over 90% of patients should come through their surgery without complications. Our review in 2012 demonstrated good outcome in the majority of patients.

The specific risks:

Failure to benefit or to prevent deterioration

Worsening of pain

Infection

Bleeding and a need for Blood transfusion

Nerve damage (weakness, numbness, pain) occurs in less than 1%

Cerebrospinal fluid (brain fluid) leak: this risk is much higher in revision (re-operation) surgery

Surgery at incorrect level (this is rare, as X-rays are used during surgery to confirm the level)

Major neurological problems are very rare, but include paralysis, damage to a nerve, problems passing urine or stool and loss of erection.

Chronic pain (may require further surgery)

You must tell your surgeon:

About blood clotting or bleeding problems

If you have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)

Are taking aspirin, clopidogrel, warfarin, or anything else (even some herbal supplements) that might thin your blood

About high blood pressure

About any allergies to drugs or following previous operations

Any other health problems even if it seems unimportant

Before Surgery:

Please bring all your regular medications with you to hospital.

Consult with your surgeon if you are taking blood-thinning medications.

You may continue to take your routine medications (for example, heart and blood pressure medications), on the morning of surgery with a sip of water (unless otherwise directed).

You may not eat anything after midnight, the night before surgery and must cease drinking clear fluids (water, apple juice, black tea) 2 hours prior to your admission time (unless otherwise instructed.)

Please shower on the morning of admission. Do not use powder, apply perfume, makeup or nail polish and wear cotton underwear if possible.

Please be sure to take the following to the hospital for the operation; MRI/Xray/C.T Scans and all previous medical reports and results. Before your surgery it is imperative that you stop smoking, and you should not smoke for at least 12 months after. Smoking impairs the healing process and leads to worse outcomes following spinal surgery.

The operation:

A general anaesthetic will be administered to put you to sleep. A breathing tube (‘endotracheal tube’) will be inserted into your throat and antibiotics and steroids given (to prevent infection and post-operative nausea). A catheter will be inserted into your bladder to prevent bladder distension during surgery and to monitor urine output. You will be placed face-up or face-down on the operating table depending on the type of surgery you are having. An x-ray is often performed to confirm that the surgeon is at the correct level for your operation. The team then performs the operation and finish when the surgeon is happy the aims of the operation have been achieved. A final X-ray is taken and the wound is closed with sutures or with staples.

You are then transferred back to the ward to commence your recovery from the anaesthesia and the operation. Once you are fully awake and well, we start making plans for your discharge home within a few days and subsequent visits to the clinic for post operative care.

So if you need a back operation:

The operations are being performed safely in Nigeria, everyday, and many patients are benefiting from the procedures. Be clear in your mind that you have exhausted all other reasonable treatments such as weight loss, regular exercise, medication and even meditation. Be prayerful and trust in your surgeon for a successful outcome. Have no fear and trust in God to heal you.

  1, Nice normal MRI scan, 2, MRI with pressure on the nerves, 3, MRI showing destruction of the bones and prolapsed disc causing pressure on the nerves.

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USE YOUR HEAD OR LOSE IT

London, UK

Many hospitals in the UK are built with a good dose of reality. I found that most of the hospitals have a cemetery attached to them. The cemetery was either in front, across the road or behind the hospital. This is important and evidence of some degree of sensible planning. Because, for people who go into a hospital, its either you go back home or perhaps cross the road to the other side!

Lagos, Nigeria

In Nigeria, we are a little different. We do not believe that people can die in hospitals. Therefore many hospitals have their mortuaries hidden somewhere and not easily identified. Many and none that I can recall have a cemetery attached. Which is good, since we should not always copy what the Englishman does?

Where we do well is that when we build roads we display an uncanny sense of similar reality. Take for instance the huge artery called Ikorodu road in Lagos. It is built within the city and in now, a largely residential area. So, people are almost forced to have to cross the road. As they say, the grass is greener, and there is always something to do on the other side!

So therefore, people cross the road and get knocked down. What are we to do? Ha, I know, let us build a hospital close by. Hence, the National Orthopedic Hospital, Igbobi was born. If you get knocked down, no problem, there is a hospital close by for managing your head injury and fractures. Smart! Igbobi is full to the brim and dripping wet with accident victims.

Use your head or lose it

I saw a great picture showing a Fulani chap herding his cattle across the road over the pedestrian bridge. Under the same bridge, Nigerians are running across the road! You will see the young, the old, couples and pregnant women take their lives in their hands and chance death. It seems to me that cows are smarter.

How long will it take to go over the bridge? How long will it take to get knocked down? How many people are knocked down daily? What are the percentages? Just do the sums in your heads and don’t bother to send me the answers. However, all I know is that you only need one failure to succeed in meeting the Almighty. Or you could end up in one of our fabulous hospitals.

Hospitals in Nigeria are no fun and they are expensive to boot. The pain and misery that emanates from hospitals is enough to darken the skies and cause a torrential rainfall. They are not places you want to visit unless you have a good reason. The reason could be that you are a single pastor and looking for a wife among the nurses. Some pastors see visions at night and get text messages from God that a particular nurse has been chosen for them. Usually, the nice beautiful nurse they saw the last time they came to preach on the ward. Very smart! Use what you have to get what you want.

Sorry, I digressed!

Don’t lose your head

Town planners and estate developers will love this article. Perhaps government officials in the Ministry of Road and Transport will also find it a bit interesting. Who knows? But, I cannot be truly sure about them because even if they have good intentions, their hands are often tied behind their backs!

What is true, to a small extent is that the government is making serious attempts to stop people from crossing the highways and getting killed. Barricades and central dividers are constantly being erected and yet, constantly being pulled down by the natives as people continues to perish on our roads. This approach is therefore not working!

We need innovative approaches other than building more pedestrian crossings, or more barricades. Our town planners and developers need to look closely at this as a big problem and do something about it. Painting Zebra lines on the roads is also simply not the answer. Nigerians do not respect Zebra crossing and believe it’s made only for Zebras.

Running across the road is dangerous. Crossing the road in any busy town is a risky operation, crossing major highways within our cities is an invitation to increase patronage at the hospitals. I am sure that the long term answer is segregation of the pedestrian from the traffic. How can we prevent the pedestrian from crossing the road just about anywhere? How can we give them the right incentive to cross in complete safety over the pedestrian crossing or at certain crossing points? I hope our university dons, students, business people and entrepreneurs will evaluate the problem and come up with better and practical solutions.

Do we have to beg people not to cross the roads? Do we have to block off access to the roads in major residential areas? Do we need the Police and other forces to physically prevent people from killing themselves? Can we simply ask that you be sensible and make the right choices?

Use your head or lose it!

NB: Please share and publish this widely. Let us get a few more people to keep their heads.

I am so happy I could die right now

Today was a colossal day. It was just that kind of day. I woke up feeling great and prepared to have a fabulous day. Usually, I wake up early, either by myself or due to the impertinent call to prayer from the loudspeakers of the local mosque. Of course, as you do, the first thing is to offer prayers to God for sparing my life, for at least another day. It’s always luck to wake up each morning. For who knows! That’s why, personally, I hate planning for tomorrow and always push to accomplish my goals each day. So in case death come calling, the jobs’ done.

Anyway, that’s not the point of this article.

I woke up feeling like a Billion dollars (No, not 20B). It clicked in my head that I had indulged the day before and so needed to go for a run and lose some fat. I thought I should lose some fat around my stomach as my belly button is slowly disappearing. So, I grabbed my running clothes and trainers, my mobile phone and the house keys and stepped out. On the phone, tuned to 96.9FM was the fabulous DJ TTB spinning some great Naija tunes. What a delight!

The Nigerian music industry is blessed with some great talents right now. I almost started dancing on the steps just loving Davido, Savage and the like. But, I remembered the plan and started the stretching exercises: arms and legs. After a few minutes, I set off on the 30 minutes daily exercise routine, running around the block. At 6 in the morning only a few other hardy fellows are about, running or simply walking. The weather was crisp, air fresh and the music delicious. The mix interchanged smoothly, banging from ‘I am looking for my Johnny’ to ‘Personally, I rock your body’.

Back on the run, I am breathing easy and frequently changing steps to the music, just loving it. I am sweating lightly as I overtake another runner. In the estate, a chap takes a group fitness exercise program in the mornings and he is busy setting up the music. A few people have driven down to take part. Driving to the exercise class? What’s that about?

A few people have started washing their cars and the water is making a mess on the street. I wondered why they cannot direct the water into the flower beds: kill one bird with 2 stones, so to say! Have to be careful on wet roads so as not to slip and break a leg. This is one reason to jog in daylight and not at night. The second reason, to see where you step is the numerous open manholes on the streets of Abuja. If you fall into one of them, you are sure to break your leg in more than a few places. Then, you will need Cedarcrest Hospital.

Where are my patients with back pain, hypertension, diabetes and stress? Where are the fat people, I wondered? They should be out here jogging and making some effort to lose weight. All I see on my runs usually are slim people with the exception of one lady. She has a lot of front and back packed into a tight T-shirt and body hugging jogging bottoms. She should not have been out this early, I thought! Surely, someone should have kept her under arrest. Anyway, I quickly reprimand myself, remembering my dear wife and her admonishing demeanour.

Anyway, early morning sex is also touted as a good form of exercise and another way to brighten up your day. It releases feel good hormones and puts a smile on your face. It can also help with blood pressure control, but, do not forget to take your prescribed drugs. Exercise leads to better control of blood pressure, blood sugar, weight and therefore reduces the risks of stroke and heart attacks. Regular walks, runs or jogging is guaranteed to keep you awake, refreshed and alive for longer. It is also fun and can be painless if you wake up with a great DJ on the radio station.

So, let me get to the point of this article.

You need to get off your backside and do something. You can walk, jog, run or crawl to keep fit. However, I would recommend jogging to some great beats at your own pace. I would also recommend dancing at home or out. Dance with your wife and kids or with friends as we do at Lifebridge Diagnostic Centre, in Abuja. Do it regularly, do it with a smile and be happy. It will increase your life span.

I so enjoyed my early morning run, I could die right now and die a happy man. So, I enjoin you today to do something different and do different things with your life!

The Fulani herdsman herded his cattle on the pedestrian bridge to cross over a busy road.

Right under the bridge, other people were running across the road like chickens!

Use your head is all we'll say.

Laser spine surgery, a fool and his gold

A patient called me recently asking for a referral letter to travel to Dubai for surgery. Apparently, I had seen the patient a few years ago, offered spine surgery, accepted and then failed to turn up. It seems the fear of spine operations in Nigeria and the need for a second opinion led to an interesting decision. The decision has been made to travel to Dubai for Laser Spine Surgery or as some also call it, ‘bloodless surgery’. Hence the phone calls asking for me to write a referral letter.

What is laser?

A laser is a light beam that can be focused on a very small area. The ‘light’ heats cells in the area being treated until they "burst." There are several types of lasers and each has specific uses. Types of lasers include the carbon dioxide (CO2) laser, the YAG (yttrium aluminum garnet) laser, alexandrite, KTP, and the pulsed dye laser.

A laser (focused beam of light) can be used for cutting soft tissue. In eye surgery, they are definitely useful and have been used to treat glaucoma as reported recently by Professor Femi Babalola. They are also used for treating the lens in our eyes in corrective lens surgery. This helps to avoid wearing glasses in some people with short or long sightedness.

Laser surgery is also useful in treating some cancers, abnormal blood vessels and kidney/bladder stones. Laser surgery is a relatively popular and non-invasive method of haemorrhoidectomy (treatment of piles). Laser surgery may also be used to remove wrinkles, tattoos, birthmarks and to treat some skin diseases.

Laser Spine Surgery

I have sometimes been asked by patients if their spine surgery can be done with a laser. There is a perception by some half educated Nigerians that laser spine surgery is a modern, almost futuristic, high tech, low risk, up and coming technology. The reality is that lasers have been around for a long time and are almost completely useless when it comes to spine surgery.

Spine surgery

In the spine, we use something called electrocautery. This uses electricity to generate heat and we use that to cut. It is much more practical for cutting soft tissue and also stops the bleeding that occurs. Lasers can cut the disc (the shock absorber between bones in the spine). But, it is far easier and more reliable to just simply grab the disc yourself and remove it from where it is compressing the nerve. Also, since discs lie right next to the nerve, one risks the chance of damaging the nerve with the laser. Finally, lasers cannot cut bone so they cannot be used to treat patients with narrowing of the spine.

Just business

It seems that the most practical use for lasers in spine surgery is for marketing. Like most businesses, spine surgery is very competitive, and having an edge in marketing can make a practice standout. Many of the foreign hospitals touting laser spine surgery use it to attract unsuspecting customers. The laser will be of little or no useful function during the surgery.

Hence, at the major spine meetings and in the major spine journals there is a paucity of (if any) articles documenting any use of lasers in spine surgery. Articles on laser spine surgery are few and far between as it is not an accepted spine treatment procedure. Laser cannot be used to treat real spine problems.

Colonial mentality

Lasers are often perceived as an effective treatment for spine diseases because of two reasons: placebo response, and the tendency to always think the second opinion (read: white skin!) sounds more knowledgeable.

I once heard that a Nigerian patient called a hospital in Abuja and asked them, ‘I hope you have white doctors in your hospital?’ Apparently, he did not want to get there and have to see a black (Nigerian) doctor. Sadly, of course, this was before the scandal broke that the hospital had been using junior doctors and others pretending to be fully trained consultants.

A fool and his gold

So, my patients hankering after minimally invasive, bloodless and laser spine surgery do need to be careful they are not used for money. Many unscrupulous doctors especially in private practice abroad use tricks and false promises to ensnare the fool and make him part with his gold. Our colonial mentality helps to facilitate the enslavement.

Designer operations

In conclusion, spine surgery is an individual thing. Operations are designed specifically for each patient and what Joe had may not be suitable for Adamu. Operations are often designed to achieve one of two results: remove pain or to free the nerve from compression. The pain may be coming because of pressure on the nerve or instability of the bones. So, operations may be to free the nerves or to fix the bone or both. More often than not, the surgery will involve cutting of the skin to get to the bones or nerves.

You can do that through a tiny hole (minimally invasive: using a microscope or by using special tubes and cameras) or through a hole wide enough for a surgeon and his assistant to climb into. What do you care, so long as the job is done and you are free of pain!

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Age and spine surgery in Nigeria

Dr. Biodun Ogungbo

 

Mama Catherine suffers from back and leg pains. She was finding it increasingly difficult to walk and so was becoming dependent on family members for help. A previously active and independent woman, she has become incapacitated and reduced to enforced bed rest. Her MRI scan showed she had a narrowing in her spine and could benefit from surgery. However, Mama is almost 90 years old! What should we do?

Chief Nkwocha was disabled by back pain. He walks slowly using a cane and can only take a few steps before the pain arrives. He then has to bend forward or sit down or else his legs might give way. The pain, as described, was severe, unrelenting and associated with numbness in the legs. His MRI scan showed multiple levels of narrowing in his spine due to arthritis. He would benefit from surgery. However, he is 80 years old, suffering from hypertension and diabetes. What should we do?

Mama Yunusa stopped walking in March. Her arms and legs simply stopped moving. She also complained about pain in the neck. She was effectively bedridden and had to be carried to the bathroom by her daughter. A fiercely independent woman was reduced to a helpless state and indignity. Her MRI scan showed severe pressure on her spinal cord – by arthritis. She also needs an operation. She is 80 years old. What should we do?

Arthritis in the elderly

The causes of back pain are nearly as numerous as terms used to describe the symptoms. Back pain is a primary reason people seek medical attention. Considering that almost 80% of the adult population will encounter some form of back pain, it could be said that back pain is a universal epidemic. Back pain respects no age, economic, or ethnic barriers. Everyone will likely suffer from back pain at some time in their life. More and more elderly will suffer from back pains, neck pain due to the degeneration caused by arthritis. Arthritis is one of God’s apps: a computer program embedded in our genes!

Arthritis causes wearing out of the bones and pressure on the nerves and spinal cord. This destruction of the bone causes instability which may require operation to reinforce the bones. The pressure on the nerves may require operation to free the nerves and release the pressure.

Age and spine surgery

There is real fear of spine surgery, especially in the elderly. The poor results of the past are still clouding the present and jeopardising the future. The fear is of paralysis and death as well as of becoming disabled due to weakness of an arm or leg. Because of this, many patients are not offered surgery and instead are taken to the village or to church. Many are left at home in pain until death eventually comes. Before death though, someone has to look after mama or papa, and someone may have to leave employment to stay home with them.

More importantly, what is happening in the present? How many days will mama or papa suffer in pain, helpless and hopeless? How much pain can they tolerate? How can you cope with the misery and the cries in the middle of the night?

The important issue as regards planning for surgery is a firm diagnosis, clear evaluation of the physical status of the patient, assessment of the fitness for surgery, a clear surgical plan, honest balance of the benefits and risks of surgery in the hands of the surgeon and effective post- operative support by spine-trained physiotherapists.

Surgery on the spine is safe if performed by experienced surgeons and with adequate expert support from the nurses and physiotherapists. Elderly patients suffering from arthritis of the spine should not be left in pains and misery. Something should be done when an older person starts crying in the mornings and praying for early death on dark nights.

What to do?

We evaluated Mama Catherine and offered her surgery. She tolerated the procedure well and has a new lease of life. She can stand and walk freely. She can go to and from the bathroom without support and is becoming independent daily.

Papa Nkwocha was prepared for operation after careful stabilisation of his blood pressure and blood sugar. This required a specialist physician to sort him out before, during and after surgery. He had his spine decompressed in a two-hour operation and was discharged home in great condition.

Mama Yunusa also required urgent operation on her neck to decompress the spinal cord. The operation was well tolerated and she has recovered well. She is still paralysed but showing early signs of improvement. At least, she now has a smile on her face and feels that the future is bright.

Spine fixed in Nigeria

Age is no barrier to surgery in the elderly. If it can be done safely and if the benefits outweigh the risks, then , no problem! Of course, no one can guarantee 100 per cent success but the majority will benefit and have a new future.

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.