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!

.

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.

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.