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.

 

ARTHRITIS IS GOD’S PRESCRIPTION

May you grow old and decrepit?

If you answered amen to that prayer, then you already know and agree with my title, that arthritis is one of the gifts that come with old age. Arthritis is God’s prescription and must be taken by everyone. It is akin to slow death into old age. Old age comes with its own baggage of poor eye sight, poor hearing, weak heart and weak bones. As we age, we slowly fall apart and become frail. The bones degenerate, lose their supporting ligaments and rub together (arthritis). This degeneration is what can then lead to the pain and swelling around joints of the body. It leads to neck pains, back pains, hip pains and knee pains. Depending on your body status, usage and of course occupation, the symptoms can be none, mild, moderate or severe.

Anyway, forgive my sanctimonious ramblings and let us talk about prevention of arthritis.

Arthritis starts from about 20 years of age in most people. Soon as we finish growing, we start to deteriorate which is what happens with arthritis. The best treatment for arthritis is prevention. The very best way to prevent arthritis is to die young. But, we do not want to do that! So the next best way is to ensure you live a lifestyle free of obesity, constant body trauma from occupations that cause repetitive injuries, punishing sporting activities and smoking.

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

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

Other joints such as hips and knees can be affected in arthritis and can lead to a miserable life. The treatment for arthritis in general is prevention and exercises. You must keep active and mobile as sedentary living causes the joints to stiffen up and lead to worsening of the condition. Do some physical activity, if possible, and consider others such as breathing exercises, physiotherapy, massage, acupuncture, and aerobics therapy. Apart from improving physical health, other benefits include stress relief, improving sleep and the additional benefits from socialising with other people.

Drugs treatment

Drugs can help to reduce the pain so making it easy for the patient to exercise. The commoner drugs used are Paracetamol, Ibuprofen and Diclofenac. There are other drugs such as Amitriptyline, Carbamazepine, Pregabalin and Gabapentin which are however not often used to the maximum dose before being substituted. Drug combinations should take into consideration, the mode of action and duration of action of the drug. This means that different types of drugs that work through different mechanisms should be used. We also have an irrational fear of the pretty strong pain killers due to ‘possible’ complications. The fear of complications causes many doctors to avoid good drugs.

Surgery for arthritis

Surgery for arthritis of the spine depends on the cause and the condition. It may be simple or complex involving the use of implants to hold the spine together. For arthritis of the hips and knees, a new hip or knee may be required. Those who cannot be operated upon or who do not need an operation can also be helped by injections, physical therapy and advice.

However, patients need to know that arthritis is not curable. It is treatable and manageable but cannot be cured. Because like I said before, it is God’s own prescription. Prayers can help but prevention by healthy living is very important to avoid surgery.

PEDIGUARD

PediGuard for accessing the pedicle safely in spine operations
 
PediGuard uses electrical conductivity differentiation at its tip for assessing bone versus soft tissue in order to improve the safe positioning of pedicle screws. PediGuard not only warns of impending medial breach but also is the only real-time device available to non-radiographically detect lateral breach. 

About the PediGuard® platform

Co-invented by Maurice Bourlion, Ph.D., Ciaran Bolger, M.D., Ph.D., and Alain Vanquaethem, Biomedical Engineer, PediGuard is the world’s first and only handheld device capable of alerting surgeons to potential pedicular or vertebral breaches. Real-time feedback is provided via audio and visual signals. More than 20,000 procedures have been performed with PediGuard on all continents. Several studies published in peer-reviewed medical and scientific journals have demonstrated that PediGuard presents an accuracy rate as high as 97.5%, doubles the pedicle breach-detection rate, limits radiation exposure by up to 73%, decreases by 15% the average time for pedicle screw placement and provides a 3-fold reduction in neuro-monitoring events. 

In the Chaput study, because of the use of PediGuard, the number of fluoroscopy shots was able to be reduced by 30% compared to a standard drilling probe while maintaining a 97.5% accurate, safe screw placement.

Spine surgeons’ increasingly greater reliance on fluoroscopy during procedures exposes the entire OR team to dangerous radiation:

• The average spine surgeon will receive the maximum allowable lifetime exposure of radiation for classified workers within 10 years of practice (Ul Haque, Shufflebarger et al, 2006);
• The radiation exposure in spine surgery has been found to be 10 to 12 times greater than the radiation exposure during other fluoroscopically assisted non-spinal musculoskeletal procedures (Rampersaud, 2000);
• The highest amount of fluoro intensity is needed for spinal procedures (Orthopedics this Week, 2010).

Co-founded in 2009 by Pierre Jérôme and Stéphane Bette, former executives at Medtronic Sofamor-Danek and SpineVision, SpineGuard’s primary objective is to establish its FDA-cleared and CE Marked PediGuard® device as the global standard of care for safer pedicle screw placement in spine surgery.

 
SpineGuard’s PediGuard® Device Reduces by 30% Spine Surgeons’ Radiation Exposure from Fluoroscopy While Maintaining a 97.5% Accurate Pedicle Screw Placement During Lumbar Spine Fusion:Prospective, randomized, controlled study results published in Spine

 

Believe in Nigeria as we publish our results of spine operations

Reporting good outcomes
There have now been 3 articles published on surgical treatment for spine conditions in Nigeria. The reports are from Lagos and Abuja. And there are many more to come as surgeons embrace reporting of their management of patients with spine and spinal cord problems. Previously, almost all the articles have been on conservative or non surgical treatments and the fear of surgery in Nigeria had driven many patients to other countries.

But, with the increase in expertise and improvements in safety in surgery on the spine, more patients are being treated locally. Doctors reporting their results will also help in improving local confidence and expertise. Everybody and especially Nigerians will benefit.

Promoting quality of care 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 a quality care. Some are also in our public hospitals. As usual, lack of information on what is available locally impairs access to good care.

Spine: Plans for Abuja

You need to know that the future is bright, for patients in Abuja with spine problems. 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.

There are also competent nurses and physiotherapists to manage patients following operations. Those who cannot be operated upon or who do not need an operation can also be helped by injections, physical therapy and advice.

Believe in Nigeria

At least in the management of bone and spine diseases: We can treat patients confidently.

So, now you know that spine problems should no longer be a reason to travel out of Nigeria. We need the confidence of the people and their trust to move us further forward. 


SPINE: Fixed in Abuja
ABUJA is SPINE capital of Nigeria

Because YOU need to know

It is important for doctors and most other professionals to have a directory of specialists they can call for help. You need the numbers and contact details of some people on speed dial. Just in case.

Some of my patients had been to several hospitals before finding their way to me. Some have been to as many as 5 different hospitals looking for an orthopaedic surgeon, brain surgeon or urologist or any number of specialists. Meantime, many have become permanently injured or died as a result of this merry go round. Do you need examples?

Take my own personal example. My mother died several years ago. Shortly before she died, we realised she needed kidney dialysis. So we started asking around. And driving from one hospital to another for information on where dialysis and a specialist could be found. Alas, by the time we eventually discovered a place somewhere in Ikeja, Lagos, she had given up the ghost. Now, that was over 15 years ago. Sadly, not much has changed in the last 15 years, except of course you consider the deterioration, change. 

A doctor died recently and he may have been helped if the right person and the equipment were at hand to save him. Apparently, he had been coughing up blood. He needed a specialist to look down his lungs to see what was bleeding and perhaps sort it out. Sadly, since help was not forthcoming, he died, drowning in his own blood. Other doctors have died in similar circumstances simply because they and their colleagues have no clue as to where help can be found. Even within their hospitals!

Many doctors and healthcare practitioners remain so myopic that they see no further than their flat noses. Some do not know about the services and specialists around them who may be able to get them out of a jam. Few doctors can list the names and telephone numbers of 10 specialists in 10 different fields. The implication is obvious. If the people, who are supposed to know, do not know, how will the poor patient and their relatives fare? Yet, the problems we face are sometimes too close and personal. The recent deaths should emphasise that we are mortal and destined to suffer the same as the patients we treat and oh, so mistreat. It could be you and you may not be able to get a visa to ‘Sokoto’ in the time it takes to die.

We need to know

I attended a meeting of radiologists in the recent past. They were giving lectures on breast cancer and uterine fibroids. Unfortunately, the lecturers, seasoned radiologists, were poor in the content of their delivery. They were busy quoting the literature and old textbooks that the audience could be forgiven for thinking they were back in the university. What we needed was: what is the condition, how is it managed, can you manage it, where are you based and how many have you treated. Following that, what are your results and outcomes so that we can send patients to you? We need to promote what can be done and what is being done in Nigeria so patients know where to go for succour. Too many people are being killed by ignorance and charlatans for us not to care. 

Be selfish

Being informed and knowing what is available locally is vitally important. We have to become obsessive and completely selfish in our approach to gaining information and knowledge. Information is power and critical health information can save lives and money. Know what is happening around you, who is new in town and what skills they possess. Also, what new services are now available in your local area? Try and see further than your nose: just in case. 

Healthcare Directory

The solution to all this is pretty simple. What is needed is a healthcare directory with information as to who and what is where. Who are the specialists, specialist hospitals and specialist equipment and services in each local area? You need to know who is available and close by to help. We need to know what is available and achievable in Nigeria. Nigerians need information to help reduce the carnage in the health industry.

The Ministry of Health Initiative

The MOH initiated the process of collecting information about skills and services in Nigerian hospitals recently. This long term project hopefully will bear fruit in promoting and educating Nigeria. The beauty of the initiative however lies in the number of deaths and disability it will potentially prevent. It should be actively supported by all hospitals.

The Abuja Healthcare Directory

The Abuja Healthcare Directory was created in 2011 and is updated yearly. It contains the names of many of the hospitals in Abuja. It also contains the names and telephone numbers of a few specialists and specialist services in the FCT. The directory is a small contribution in improving access to vital healthcare information. It provides easy access to specialist services and hospitals. Patients and their relatives can now go directly to the hospital where the needed services can be provided without having to waste time going around in a circle. The Nigerian Healthcare Journal is an online portal that carries the directory and so information can be accessed via laptops, mobile phones and the like. It is also available in hard copies.

Other websites exist and more local directories need to be developed. It is our collective responsibility as doctors and healthcare practitioners to participate actively in these endeavours of both the government and private parties. The Nigeria Medical Association, Guild of Medical Directors and the Association of General Private Medical Practitioners of Nigeria must all take a lead in supporting and promoting these ideas. 

Because we simply need to know!