0:02
SNI, Surgical Neurology International, an Internet Journal with Nancy Epstein-MDS, etc, in chief, an SNI Digital, a new video journal, interactive with discussion on innovations and learning in
0:22
association with the Sub-Saharan African neurosurgeons are pleased to present another in a series of Sub-Saharan Africa International Neurosurgery Grand Rounds, the fourteenth such meetings on the
0:41
first Sunday of each month. Sub-Saharan African
0:56
International Neurosurgery Grand Rounds is devoted to global solutions to clinical challenges in neurosurgery It is moderated by Estrada Bernard and James Owseman. It has an international audience.
1:07
This meeting was on Sunday, August 3rd, 2025.
1:12
We'll be by Professor Nimrod McWombi,
1:18
who's in Kenya, Kenyatta University, and it'll
1:23
be on
1:27
cranial vertebral anomalies And this is a view of Kenya on the east side of Africa, and that Professor McWombi is from Nairobi. Well, Nim is setting up, there were questions about whether we use
1:39
endoscopy. No, we didn't use endoscopy. We did a microdecectomy, basically, with a
1:47
tubular retractor kind of setup. Someone asked if the tubular retractor is better than the Casper retractor I think the tubular retractor system has less. less tissue disturbance. And so there's an
2:00
advantage of that in terms of that. But as far as outcomes is concerned, I wouldn't say one is better than the other. And certainly, as Dr. Osman pointed out, there's a conventional approach we
2:15
would have provided for excellent outcomes just as well. It's just a matter of the type of exposure and
2:30
the degree
2:33
of tissue dissection Okay, thank you very much. You can see my screen. Yes, you can. Okay, thanks very much. Fine, so I'm
2:41
going to discuss clinical vertebra anomaly in summary. Clinical cervical junction abnormalities are congenital, acquired abnormalities of the occipital bone for an acronym were the first to cervical
2:49
vertebra that decreases face of the lower brain stem and Suego code. These abnormalities can result in necrology. ringomyelia, cellabella, lower cranial nerves, and spinal cord deficits, and
3:00
vertebrae vaselase kidney. Diagnosis is by MRI or computer tomography. Treatment of 10 involves reduction followed by stabilization, via surgery or an external device. So another view of our case
3:14
is we're going to present an adult female with a kerotype 1 malformation with associated anomalies of the coronavirus reduction who became symptomatic following up fall from stairs. She was managed
3:25
in Arabic, Kenya, after appropriate imaging studies. This is her case summary. She was she's a 32-year-old female, gravid and nine, who presented with a
3:35
three-year history of neck pain, one-year history of both up and low limb weakness, tingly sensation, a stretch with dysphonia and dysphyseia, and drooling of the saliva, following up fall from
3:46
the stairs. One examination shows spastic quadripiruses four over five. She also had astagmas, dysphonia, altered pain, touch, and proprioception, with paralysis of the lower cranial nose,
3:60
both 9, 10, 11, and 12, and dysarcyl and the intentional tremors. Our clinical impression at that time was apaceveco spine, or brainstem compression, secondary to a fall. We also coiled it
4:12
that probably because this happened as a result of a fall. Maybe those are clinical rejection or no matter, maybe.
4:22
After appropriate investigation, she underwent posterior foster decompression after imaging, which was done on 4th December. And there was no improvement. Her symptoms wasn't, and then she was
4:32
re-admitted. The following year, and having had images done again, and during that re-admission, she had occipital cervical vision. So she had two procedures for management of her condition at
4:43
different times. The first one, she hadn't improved, and therefore, that's when the second one was done. So we're going to share with you the images, And these are the pre-op images which were
4:56
done before the posterior faucity compression. Now, as you will not from these images, this is an MRI which was done and you'll see you'll not hear that the odontoid has been displaced upwards
5:10
above the level of the following Magnum. So with the odontoid displaced upwards and then there's also retroflexion of the odontoid is compressing the brainstem and that explains the symptoms of the
5:23
lower cranial nerve which we saw in dispersion which were related to the compression of the brainstem.
5:32
Following that, then of course the MRI report, the important bit here is the caffolate migration of the tip of the dense, that is the important bit and then the other one which I forgot to show you
5:44
here also was the tonsils which had come down. So the tonsils also had come down So we then, made an impression of that, those are cellular tonsils below the level of the following magna, and
5:58
those crowding with the following magna. The rest of the examination really didn't give anything which was significant. And then conclusions was that this was a patient who had to carry one
6:10
malformation, and there was medallocompression due to bazzling, vagination, and carry one malformation. There was no features of male malecia, but there was crowding of the following magna Now,
6:23
from these findings, this is where the patient went to undergo surgery, but let's see if you also, the CT scan features here, and you can see from this CT scan features, they are onto it.
6:38
cities, can features, you can see the atlend axial joint has been widened. And this widening of the atlend axial joint then convinced as that probably goes instability at the atlend axial joint,
6:51
maybe this
6:54
was related to some tail ligaments, maybe the transverse ligaments, but this would explain the reason why this lady as a result of this minor fall from the stairs, you know, because of the
7:07
instability at that clinical cervical junction, it resulted in heart deterioration and getting all these very, very severe symptoms such
7:20
that she literally needed to be supported while she was brought in hospital. I must also add that this is a patient who was referred to the National Referral Hospital from about 400 miles from where
7:30
she lives in, so 400 miles from Nairobi So that decision was made. I will emphasize that this was in 10 to 2015, that's quite some time ago. So the decision was made to give the expression to
7:46
posterior prosthetic compression and this was that no other form of treatment was offered. This is the treatment we were offering many of our patients who had
7:58
tonsillination at that time. So here I want my information we're offering prosthetic compression I do not offer any other form of treatment. So in part of the fact that this patient was had a
8:07
baselay imagination and had an adrenaline to exo instability. So but we
8:19
didn't know that further treatment for that was not offered. Invariably she didn't improve and she came back again to about two, three months later for a review. So this was in disabarsity. So she
8:33
came back in general for review. The images were repeated. And these images, basically they just confirmed what was there in the earlier images. Only that you must know that there is no swing of
8:45
my area in our patient. And the only
8:51
part of the challenge we are having here is the Baselian Virginians and the Toussala Nation, which our treatment doesn't seem to have helped her very much. So the MRI report, which was repeated,
9:01
again, it just confirms the compression of the medulla by the retroflex genes and the cellular tonsils were below the firm magna. And the other feature which was dotted was the reduced, believe us
9:14
a vehicle, now was reported, the reduced, increased vehicle angle, this one basically confirms the Baselian Virginians.
9:24
So again, as I said, there was no serene gomaelia. So we didn't have to worry about the management of that one. So with that, then we proceeded to consider the second surgery, which now was to
9:38
consider to perform a form of oxygen cervical fission, which was done now after appropriate proportions. Remember this patient had already had posterior facetic compression, so that we now had to
9:51
move slightly a bit laterally and put your looks of cervical fission. So I'll share with you the images which were done
10:00
after the occipital cervical fission, and
10:04
the one which is here, you can see the rows which had been placed, you see, and the rows which had been placed, that's, I think, about C3, C4.
10:19
Again, this is the treatment which you offer, this patient at this junction, as to whether it was the proper treatment or not, this is what we would like to discuss, Because again, it didn't
10:31
help out very much. And
10:37
the report was that they were still crowding at the fireman magnum. The order into a process was still above the fireman magnum. And there was some of the compression had been done. And there
10:51
was evidence of the fission which had been done. So these are difficult conditions to manage And sometimes one is left with very little alternatives, especially if maybe sometimes you don't have the
11:09
facilities to go into a more aggressive type of management. So want to
11:17
review this case. What was the problem with this patient? Now this is a developmental problem as you know that, so the issue here were the central pillars, the
11:28
centropiles were compromised. So therefore, there was this problem of the odontoid, which you say is dispassioned. And then there was this buzz-line vagulation, which this patient has as a result
11:40
of the odontoid migrating upwards to the following magna and the retroflexed odontoid, or the adenzo odontoid. And then the other challenge this patient had is the wide end adenote exo joint, which
11:51
therefore is creating adenote exo joint instability. And probably this could be as a result of that of the transverse ligament So probably this may have happened as a result of the foam. And this is
12:03
what probably led that patient to deteriorate so rapidly. So challenge I get here is what do we do for this patient we try our best, but we do seem to have gotten much, much good results
12:18
to sort of see how improved from that. I'm just sharing this slide to show you the problems which may occur in cardiovascular conjunction So, in current particulate production, where nobody's, you
12:30
can have problems, it's your cause, there's a lot of problems of the central pillar. Now, the problems of the central pillar is the one which our patient had, that is, ordered problems, and the
12:42
platypesia, and retroflexidense, that's a problem of the central pillar. You can also have, in current particulate, where nobody's as a result of the lateral components of this, the touchy
12:52
situations, that you get an crystallization of the OC1,
12:58
and all those malformations, that is now from the rings. And sometimes you can get situations where both the lateral rings have a problem, as well as the central pillar, that's a
13:12
problem. Our patient fortunately had only this problem, the central pillar, but still, it was quite a major problem, and very, very, very, very dealative to this patient I'll just give a brief
13:26
brief, just a very, very brief. outline of how we could approach or
13:34
the philosophy, which supports the management of these conditions. Number one is the issue of stability, the spine stability. And this was defined by White and Projabi, that the supporting
13:47
elements around the cranoservical junction have a major role to play in spine stability. And if the supporting elements are disturbed, then the patient are invariably concerned developing
13:60
neurological signs and symptoms. So the supporting elements in our patient was disturbed in spite of the fact that our patient had these abnormalities, but she was living comfortably with them. But
14:11
when the, as an result of her fault, those supporting elements were disturbed, then she developed symptoms. And then the other issue which I would like to mention is the guidelines which we should
14:23
use
14:25
when we are directed or we are choosing what type of surgery to perform. And again, the guidelines which were given by menaces are still still quite acceptable. In spite of the fact that there are
14:36
different different types of
14:40
surgeries which have been advocated for this, and these guidelines
14:47
are the number one, you should consider the reducibility of the lesion, whether it's an anatomical alignment can be restored or an anatomical alignment
14:54
or an sensory disorder. And sometimes if you find that this lesion is not reducible, then the type of approach will be determined by the error said, the disability of the lesion. If the lesion can
15:06
be reduced, then one may not be as aggressive. Then the other one is the direction and mechanics of the compression. So as you see our patient who had auditory retroflexion, at this source,
15:19
compressing the brainstem because of the force which occurred as a result of that. And then the etiology of the compression and the presence of suffocation centers, which will determine where the
15:31
age of the patient and by and large, most of these patients usually will have problems at the age of 14 years and above. Although one of our young especially we had was at the age of 12 years. The
15:46
types of surgery, again, just to sort of like open our discussion on this So approach of the lesion is distributed by location and nature of the compression. When pre-operative dynamics, dynamic
15:58
neurological examination demonstrates that the conversion-projection compression is a reducible neural decompression may be obtained by simply reducing the dislocation, as well as stabilizing the
16:08
cleanup of a tumor junction with posterior instrumentation. Either with wires, clothes, or screws, this is what is called referred to as functional decompression. And then the other type of
16:19
approach is the transoral approach Now, there's a neutral. discussion on trans-oral approach. In the earlier years, this was very, very much advocated, and it was popular very much in the
16:34
European settings by Alan Crockett, so the trans-oral approach. But by and large, some people, when they tried this, the complications are immense, and therefore, it wasn't as popular. But
16:48
more recently, with the endoscopic and endo-nozzle interaction, microscopic endo-nozzle modalities, then this trans-oral approach now is gaining popularity, and this should be considered,
17:04
therefore, in management of this condition. And then the other one, which we can be considered, is the direct approach, and this is an approach which as well takes into consideration that there
17:17
is at length excellent instability. And the principles here are that As a result of the bodily invagination, these patients will always have atlantic exo instability that atlantic joint is unstable.
17:32
And therefore, unless you reduce it, you cannot elevate the symptoms and the signs. And this therefore has led to the direct approach where atlantic exo joint
17:46
is approached and efficient is done and stabilization Now, Atul Guel has published this in a paper at 2015 and tried to advocate very much about this atlantic exo direct intellectual stabilization.
18:04
It is essentially, which of course has a lot of risks and one has to have a lot of experience in performing it because there are very, very many vital structures around there which in case something
18:16
goes rogue, then you send to lose almost but this is one of the. This is now one of the methods which are advocated for management of the type of case, like the one we have presented. So I'll
18:33
present it that case and we shall discuss it as we move on. But I would like also to share with you the our experience in managing cardiovascular abnormalities, because we see a lot of these cases
18:48
of cardiovascular abnormalities. And
18:50
by analogy, these patients usually tend to have short necks
18:55
and the hairline is also very low and with very limited neck movements. And they present usually as adults, but
19:09
one patient present at a very young age. Now, we also noticed that in our review of our cases, many of
19:18
these patients were tended to be from one particular ethnic group In K-Jaw we have. three ethnic groups. We have Bantu, we have Nilotic and we have Kushitek. Now this is basically the way is which
19:29
is found in most of the areas of Africa, in central Africa and in southern Africa. Then Kushitek are the ones who are found mainly in Ethiopia and Somalis. So most of our cases were from the first
19:47
ethnic group, the Bantus, and also amongst the first ethnic group, the Bantus, was only seen among certain tribes, that is the Kikuyus, Louisa, and Kambas, but it was not seen amongst other
19:60
tribes. And amongst the tribes, this condition was seen in the University of Riojunctional Nomadis, most of them were in the highlands of Kenya. So the ones who were in the lowerlands of Kenya in
20:11
the coastal region, these cases were hardly ever there. So we published that paper and most of our patients presented with Please. symptoms of weakness of the extremities. This may be because our
20:25
patients present late, so that's why probably they were against the extremities. And then there are other symptoms who are just like seeing elsewhere. And this was due before the CT scan became
20:36
available, so before the CT scan became available, most of our patients were being investigated using the tomograms, not the CT scan
20:48
MRI. So these patients who I have presented in this series were diagnosed using the CT scan and the tomograms and
20:59
myelography, but not the MRI. So all the patients who we published at that time were able to diagnose all these conditions. And as you're not there,
21:10
in person who was the comor, I did, of course, it's a patient who's an adolescent atlas, and at length, it's
21:18
all dislocation, a key animal formation, and selingo. myelia and this is just to demonstrate to you how even if those challenges of lack of MRI were able to make a diagnosis of these patients and
21:31
offer their treatment. Now the treatment which you were offering then of course was posterior prosthetic compression and what we found is that amongst these patients we offered posterior prosthetic
21:42
compression we had a mortality of 8 and then the remaining
21:49
50 improved, 50 did not improve but did not deteriorate. So the surgery had the effect of making the patient sure the patients did not deteriorate.
22:00
So what are the ways, let's say for the future, we must remember that there's also syndromic associations of clean vertebral junction anomalies and the Human Genome Project has associated clean
22:15
vertebral syndrome with these chromosomal abnormalities is a deletion of the chromosome 22 and 112. And the syndromic syndromes of particular anomalies, which I did not include it in our paper,
22:30
this one not day in our papers, is clipperful syndrome, down syndrome, which is quite common. And
22:41
this has opened an avenue where then the human genome project can be able to study what other genomes or other genetic problems which will lead to this. One of my colleagues has mentioned that maybe
22:56
this is due to the mode of delivery during child path. Again, that we need to consider. So in conclusion for the studies of the epidemiological pattern of clinical-tribal genetics in Indonesia or
23:11
even in Africa, which is necessary, which should include genomic studies, the development of those copy-assisted procedures, for cranial vertebral junction to cooperation with assisting the
23:21
management of the complex cranial vertebral junction pathology. With a population of about 1 billion, Africa offers varied neuropathologies that may be of immense value in the advance of medical
23:33
knowledge, as was demonstrated in the history of backwards lymphoma. This should be pursued in further studies of the cranial vertebral junction and nobody's, especially the neuroendocrinological
23:46
patterns as we have said, yeah, again, then.
23:51
Declaration, patient's consent was more obtained and the purpose of the patient was maintained and financial support was new and they have no conflict of interest. Thank you very much. Thank you,
23:55
Nym, but professor, that was a very, very good presentation in a very interesting case a lot, a lot we could talk, we could talk about Dr. Osman and I.
24:19
prior to this, I wondered about the prevalence of these particular Gary One malformation with Korean vertebral junction anomalies in particular in Africa. And so, you given your case series was
24:34
very instructive and it's fascinating that you noticed that the prevalence in that particular the Bantu ethnic group in Kenya, suggesting the genetic predisposition. Well, Professor Lager, any
24:54
comments? Yes, I mean, the most, that the feather jumps at the end is yes, you have one billion people in that the continent, you have a tremendous power of information. And I fully agree that
25:11
the all of medicine will advance through the observations and the treatments by our colleagues from the African continent. And not only adding to what I said before, not only in the structural and
25:28
anatomical thing, but in the whole understanding
25:31
of the brain, or the whole understanding of the neurosciences. So yes, congratulations and outstanding presentations. And I saw that when I did the review of cases of Keari in Africa, I saw very
25:46
few publications, but Professor Nimrod there for this one day has a name for the people who know him. That you have already like five patients with sitting in myiliya, and I
25:58
don't remember how many patients with
26:02
the Keariya, one close to four or five also, no? So yes, it is remarkable in the number and the willingness to share the information, not to repeat, to share On a donation.
26:20
And then I had a question about your patients. Were they, I presume that they not only had
26:30
symptoms like neck pain or headache, but they all had neurologic signs? Yes, they had neurologic signs, but not as severe as this patient who were presented. So the worst neurological signs was
26:46
weakness of the upper limbs and weakness of the lower limbs.
26:50
President, you have my other ear. Yes, thank you very much, Professor Nimrod. And I apologize from you and all the audience to ask this question because of my lack of knowledge, because I have
27:04
read and I have seen picture of the many African women to carry heavy loads on their head in different areas of Africa. Could it be one of the factors that they affixed because all the pressure comes
27:18
on the neck. and to affect these anomalies provoked because of the carrying heavy loads on their head. Is there anything looked at this subject? Because really it could be a contributing factor
27:36
because you have it in certain ethnicity and certain group of the people in Africa. I'm sorry if I asked this, it's just for my poor knowledge that I ask this question if you can comment on that Yes,
27:50
I can comment on that. We haven't associated that we've been carrying these heavy loads on the head at the back with any of the neurological conditions. And by the way, it's quite a common feature
28:06
in Africa. But here in Kenya, we have associated it with another condition. And we have associated with a basa, a basa at
28:17
the back So it's called Kikuyobasa. So I think Basa is a Basa which develops at the back of a woman because of the bag which she puts at the back.
28:30
And we observed, this was observed by one of
28:36
our very, very early general sergeons, very early general sergeons. The ones who observed this, and this was even before we got independent, so they published that. They noticed that they were
28:47
coming to hospital, and they had this huge swelling at the back, which had a sign of your fluid. And they wondered, and they went in to schedule, they found that it was related to cutting this
28:60
heavy bag at the back, where the strap is put on the head. So the strap is put on the head, and then the bag is at the back. So they named it
29:11
Kikuyu Basa. Kikuyu Basa, I don't know whether it's still there in the literature, but Kikuyu Basa, Kikuyu is the tribe, and this we met all from the Kikuyu tribe. So it's I'll be called to
29:19
Kukubasa, but I think this Kukubasa would be found in most of our African women in the village.
29:26
Thank you, sir. Thank you. Very interesting. Anybody else have any comments or questions?
29:33
I think just an outstanding presentation, I'm a very thoughtful, very scholarly and astrata, I think, what you all did with the, the people in Ghana was very creative under extreme circumstances
29:49
that were not under your control, making use of what you had to become very successful in doing that surgery, a very complicated problem. And I think you all had did a very good job. And for Jorge,
30:05
thank you for providing very stimulating, challenging intellectual analysis of what we don't know,
30:17
just a lot.
30:21
Yes, we're continuing to continuing to evolve. I see my, my friend, Dr. Deborah Blaze is, it's on and Dr. Blaze, do you, do you have any welcome and do you have any any comments.
30:37
Dr. Blaze has, has, was on the fact that in University Kentucky, she's in the Hagenava, I know she does international work in Barbados and I'm sure some of the, some of the challenges might be
30:50
similar. Well, can you hear me? Yes. Thank you so much for your welcome, Dr. Bernard, and this has been a wonderful
31:03
program I've enjoyed it and
31:07
you know, my work overseas and Barbados actually, we've not encountered a lot of issues I tend to bring everything that I need with me.
31:20
but this has been a very enlightening program. All right, well, thank you. And again, thank you. We reiterate Professor Lasworth. Thank you, Professor Narangambi. And thank you, Dr. Hassan.
31:35
This has been a great discussion, great lot of food for thought, very thought provoking.
31:44
Jim, any additional comments before we close out? No, maybe we can get Dr. Blades to come and present it in the future. And Elo, good luck in Tanzania, and we hope to hear from you.
32:01
Or Tanzan. Thank you. Thank you, sir. Very good, okay. Well - Very tall of you. Thank you. Thank you. Good to see you. Thank you. Thank you, everybody. Bye-bye. Bye-bye. We hope you
32:13
enjoyed this, these series of presentations.
32:18
The views and opinions expressed in these programs are those of the author and interviewee and do not necessarily reflect the official policy or position of SI digital arts management.
32:33
Information contained in this program should not be considered to be medical advice. Patients should consult their own physicians for advice as to their specific medical needs.
32:48
Please sell out your evaluation of the video. At the bottom of using the rating scale on a home page, choose one out of five stars. Five is the highest to help us improve. The information we bring
33:01
to you on SI digital.
33:06
There are many ways to learn and SI surgical neurology or national is one journal It's editor is Nancy Epstein, editor in chief. It's web address is siglobal.
33:22
SI digital is a new video journal of neurosurgery. It's web address is sidigitalorg,
33:30
and it's interactive with discussion.
33:37
SNI is a surgical neurology international, has read in 3, 239 countries and territories in its 15 years of publication, and it is the third largest readership in neurosurgery. And SNI digital
33:53
innovations and learning has been published for 16 months. It's already viewed in 152 countries It's the first video journal of neurosurgery.
34:06
The goal of the foundation supporting these programs is to help people throughout the world.
34:13
This recorded session is available free on SNIdigitalorg.
34:19
Click the icon, the blue icon at the bottom right of the homepage if you have questions, comments and requests for CME credit
34:28
This and I digital is now offering all of its programs on podcasts. Go to Apple, Amazon, or Spotify podcasts and look for SI digital
34:41
A foundation bringing this program to you also sponsors the Medical News Network to bring truthful medical and science news to the world.
34:53
These programs are copyrighted by the James I. and Carolyn, our Osmond Educational Foundation. All rights are reserved, contact Dr. Osmond at the email address below for further information.
35:06
We hope you enjoyed these programs Thank you very much
