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SNI, Surgical Neurology International, a 2D Internet Journal, and SNI Digital Innovations and Learning, a 3D video journal,
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is pleased to present an association with the Sub-Saharan African Neurosurgeons, another in the series of Sub-Saharan Africa International Neurosurgery Grand Rounds held in the first Sunday of each
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month
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The general title of the Grand Rounds is
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global solutions to clinical challenges in neurosurgery.
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The moderators are Estrada Bernard and James Ellsman.
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The title of this presentation is Challenges in Instrumental Decision Making in Lombard and Generative Spine Disease.
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Using a case presentation on failed back surgery with a global discussion of the management of these problems
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Professor Samuel Ojegelbaum was
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the neurosurgeon in chief and is the founder of Memphis Hospital for neurosurgery and other specialties and the CEO of that institution. He's the first president of the African Federation of
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Neurosurgical Societies and was at
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the University of Nigeria
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as Professor Dean and Deputy Vice-Chancellor. All of this is in Nugu, Nigeria.
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Other people involved in this talk are Dr. Okwendulow,
1:58
who is an neurosurgeon at Memphis Hospital, Professor M. Budusuci, also at
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Memphis Hospital and Dr. D. Okwendulow.
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Same, we start with your group. I know Dr. O had already started sharing his screen and did a good check and just make sure that it was working. So Dr. O, please proceed. Please introduce
2:24
yourself and proceed for the presentation. Some of which colleagues last month were started this presentation and time was against us. So the second half of it had to be postponed
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We're back on our seats today to continue the discussion with started last month. Spire surgery is a major part of our practice in Nigeria. And as I said earlier, from about 27 of our workload in
3:02
our center. And we encounter obviously problems and complications And the instrumentation is one of the areas
3:14
that.
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Soon again, Sam, I miss you said it was what can you see me? Yes, Sam, you said it was what percent of the workload you had? I missed it seven to seven percent, 37. So one out of three cases
3:35
are spine cases Are they are they mostly trauma or are they they're just regular? I mixed very mixed some trauma and a lot of spine two months. But degenerative spine disease is now the major and
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the dominant component of a spine and seizure. Interesting.
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So today we are going to continue the discussion we started by presenting two cases to illustrate some of the problems we encounter
4:10
and the opiate were took off with the first with the presentations. Thank you very much. Good evening from Nigeria. My name is Dr. Okun Nodaloo. I'm a graduate from Memphis Hospital, South-East
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Nigeria. Today we'll be discussing two cases of design decade in spine study. We'll start with one under the number of diseases in spine disease Our topic here, we'll talk about challenges used in
4:35
the professional
4:58
and so many people who have a disease. In case potential, I'm paying back. Thank you. This is the Memphis Hospital from New South Korea, Nigeria. This is the hospital, part of the hospital
4:58
around the compound. We are presenting from South-East Nigeria, in this case, as per the scene. It is considered a part of the general map As a whole, a background, Spine South-East is only
5:05
increased with changing friends in South-Saharan Africa. However, design making in is to make that number
5:13
to reduce bias on the kind of fights challenging.
5:19
But it's also a social society for the number of spine depending on the specific individual scenario. For John's training, the experience, and even There's little consensus on added precisely
5:25
indications of the known factors for any specific therapy. Technical indications for the measure of a spine surgery include abdominal motion between human body and breath, appearance, spine up,
5:33
alignment, such as possible in the stances of painful motion, stagnant, which can be excluded, particularly greater or greater. It is thought that elimination of this pain generated by a swimming
5:47
pressure won't affect symptomatic pain relief. However, that also happened in all cases. It's not suggested that as a complex or a spine surgery increases, the release of a spine surgery is also
5:56
increasing. The success of the spine surgery is also decreasing the number of the spine surgeries. About 50 of the spine surgeries may be successful perform for the first time. We successfully drop
6:06
you.
6:08
from 30 percent, 50 percent, 5 percent for the 7th year and 4th year of respect to you. Then, back-sology seemed to recognize that that's what we need to describe because it's a normal robot field
6:13
that exists or appears after a spinal surgery. To present the 7-6 year-old retired senior police officer, who came to the community with two-year sister of
6:26
required robot planes. No robot plane was installed on the onset with progressively increasing intensity with the English analog score of
6:41
vector plane The Russian director of the Russian plane was created down below 2. The plane was same as a graph in the end, severity. The Russian plane was created on a genetic location of a
6:46
polymerase, diplomacy, and anesthesia. He also had all the continuous and constipation. His robot plane, however, detected by 18 years prior to presentation, leading to a long-bar pericle
6:53
position in India, including several planes. He was relieved for some harm before the furnace of the plane However, in 2021, he had to zero, tobacco, decompression, thoracic, decompression,
7:04
and additional mobile surgery in
7:07
India. to the progression of symptoms. He had cost of practice left applying within us, which is free, after this one. However, since after the second surgery, which is due to C3, C3, C7,
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limited lung net 20, C8, C10, lung net 20, and L3 to
7:24
L5, we wish on the compression, the low back pain progressivity wasn't. The regular pain down goes free, was only left.
7:28
There
7:30
is a mention, he was an actual airline man who was not the one who was the one who was taking these threats, but the
7:38
science was quite on the market.
7:42
Did you
7:44
cannot replace this
7:52
reference on
7:59
the left?
8:08
Uncle Clunus was object and platter response was flexor, relateration. Decision was intact to be free, going to the sunset of the nonsense we are all
8:18
doing.
8:20
The back shot is midline Savayka's car, midline Corratic's car, and here is Lomba's car. With slight tenderness at the Lomba's car, he chest and abdomen are exhibition where essentially no mind.
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For a particular ideology, Lomba's car in behalf for the most accurate MRI, we showed how to sign suggestive of losing implant spoons. Also, the CT-O2 field losing L5 spoons by the time. This is
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the MRI
8:42
of
8:47
the question of Lomba MRI, swaying the L1 to L5 by M32 spoons with how to sign the test is the C1, C1, C1, and the CT2. In the showman intact, come out.
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The, this is the CT, the CT of the question, showing the L1 to L5 by M32 and stools It's them, it's me, I just look at my view.
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MRI. This is the tobacco
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MRI of the patient, children, put in an off-space, but it's available for the
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star art, or the song element of an excavated school, this is the area that showed no mask, it's available for the children. We had laboratory tests, as well, for surgery, because essentially,
9:30
no matter what the chest action on this issue, working diagnosis was filled by some people, tell you, and in touch with it. We had to be shown in class of the undergraduate in L1 to L5, 35
9:38
students' admission, and in session, it was a lifetime to don't die, it was a appetite. We talked with the findings, including a mid-line, a mid-line mobile staff, people's transportation
9:53
schools, members around the world. Distorted process and class around those, he had to lose walking school, that is the cap school from L5. This is the post-op image of of the patient showing the
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good trajectory of the school from L1 to
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L5.
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This is the lifestyle image, the pronoun image of the same patient showing good trajectory of the school. Immediate post-operaticular was on the bathroom and he was managed to work. The dream was
10:27
to move from D3 post-operaticular. He had corrections for post-opanemia, hypoabulonemia, please electrolyte anemia and deviate anemia. He was on antibiotics and organics and hematinics as well as
10:27
antiglid non-proprietary populations. He also had wonky a post-operaticular psychopraction that's about all doing it, it's subsequent and it didn't mean. Very simple, he is not however improved.
10:27
That's quite regular psychotherapy and clinical psychologists into it. He was suspended in his child's home on the peak to be post-soil
11:08
for outpatient to work First off, be sure to reviewcom. It is time to try to do the most post-op. It still has a significant go-back phase, limited mobility and dissatisfaction with outcome for
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surgery.
11:21
What are the challenges? These are making for surgery or for surgery or for another approach in clear-back surgery. Despite the challenge, what I have to go ahead and then operate the end of the
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process after that in clear-back surgery, especially when they have had multiple surgeries Like in this index case, I have multiple surgeries in India. And in the second surgery, we have, we have
11:41
books on survival and thoracic and lumbar in 160.
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That was quite amazing. Then surgery is indicated in
12:02
the index case because of implant failure and infection. There's quite multiple criteria with psychotherapies and psychotherapies and neurologists due to what these patients expect.
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Thank you. Thank you for the presentation. So that's the end of the presentation. On this case, I can tell them back and surgery is quite a big challenge for us When we have to send out a lot of
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spine
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surgery, and in this case, because of the implant failure, as well as infection, we have to do another edition surgery
12:46
for the patient. However, the patient is still on such a spiral We have also been discussing the results of the instrument in some of these cases of low back pain. We all know that we don't know
12:46
what's going on with the area, the test, but we don't know why it's orthopedic or not It is known that orthopedics are more likely to fix more segments than most of them, because they are a bit
12:56
more because they are way too tight. However, whatever it is, both of them are both in low back pain
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and stress.
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Then in light, the assets of this discussion, challenges, and which can be done, when to fix, when not to fix our registered. Thank you. Thank you very much. The, it's always disappointing
13:21
when we don't have the outcomes that we desire. I wondered about the status of the infection. Did you identify the organism that caused the infection on subsequent follow-up that the CRP
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go back into normal range? And do you have indication that the infection was resolved? Maybe you didn't hear your question.
13:51
Sorry, I can't
13:53
hear you. Did you hear me? Okay. Yeah, it's better now, we can hear. Okay. So I was, I was asking the status of the infection Did you identify the micro-organism?
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And well, I'm going to add another question. How long was your antibiotic treatment? And do you have indication that the infection was resolved? Did the CRP go back? All right, thank you, can
14:21
you help me? Can I help anybody do? We can
14:27
hear you, can you hear us?
14:33
Actually, the patient might be on antibiotics before we saw the patient, not antibiotics. So that was why the CRP was the beta and borderline. And then we started to go in with the aim of doing,
14:51
the aim of doing and so sculptural. The one we got in, we didn't have much evidence for infection again, that is why we decided to remove these tools
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and
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place another set of tools
15:08
I
15:11
think Elvin's got a question, Dr. Do, please go ahead. What's your question? Thank you very much, and this case is almost what us in Liberia will see frequently. So I just have a question.
15:24
Thank you for that brilliant presentation, Dr. O. So my question is,
15:31
was there
15:34
any need for intra-operative upon when you change those screws, when you were placing the screws? Some surgeon usually used vancomaxing powder to place white-leasing those new screws. So I don't
15:50
know what that was done also.
15:54
Okay, thank you, Dr. O. Thank you, we don't have vancomaxing and powder Watch videoscomcarrot and give you a question.
16:07
We were able to replace our screws. We tried to use put down iodine and irrigation to do source control also for the patient.
16:16
So you place the - Good job, protein. Put down. Put the probe down. So what that solution we call beta dine, so you place that into the irrigation and irrigate the field like that? Yeah, yeah,
16:28
we use it to do yes. We use it to irrigate the, but there was not any active infection going on, we didn't notice any pause I think antibiotics have been on that plate. That's where I went to the
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head to instrument. If there was active infection, what we normally do is to remove all the implants and then irrigate, you won't come out and fill the patient up with antibiotics until CRP is
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normalized before we consider going back again. Any other questions or comments? Yeah, I'd like to ask from Jay, good morning presenting symptoms on the.
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Dr. O, what were the presenting symptoms in the case? I missed that. Was it just back pain or was it back pain and infection? I missed that. It was just back pain. Just back pain, radical back
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pain. Back pain with a radical company. It's been on for some time since he had defense surgery. He had some relief, he did over 17 years ago. Then he had second surgery about five years ago.
17:13
The
17:29
10 patients had even became worse after his second surgery So he presented to us, and we had to do some images for him. And we saw and noticed that he was having some bosom screws, especially on
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the
17:42
L5 particles screws. So we did a CRP, which was borderline. I think he had taken some antibiotics. So we proceeded to do an wound exploration for him. And when we got in, we discovered there was
17:54
no actual infection going on. That is the EME screws on L5 were already losing by laterally. And some of the screws were already loose. and a construct was not rigid. So we have to remove all
18:07
these screws. I use bigger size screws, bigger size screws to fix the patient, bigger size screws.
18:18
Could you put the, I think some people just joined us. Could you put the images of the spine back up with this? And maybe that might help everybody. So he had bished back pain. And do you know,
18:31
oh, you're doing that to you Why was he operated on previously? Why was he fused? What was the problem? Yes, it was the same back pain. It was the same back pain that took him to India. Because
18:45
of the back pain, they evaluated him and felt he needed fixation. So they did L1 to L5 medical screw fixation for him in India. That was about 17 years ago, been a long time. However, five years
18:57
back, five years back, depend, record And the entire museum was this time. He went back until. division, um, fixations for him. And he, uh, that's why the division, fixations didn't persist
19:09
yet. And the second surgery, he had booked a bicycle, long, uh, thoracic and long, but literally all the regions were, were, were, were all created. You know, with
19:21
only the lowest time in the revision, kids. Despite that, he still did not, um, get benefit for the surgery. He still complained of back pain and that progress on the presented to us
19:34
Are there any questions for people, uh, uh, Kargal, you heard the case to begin with, uh, what's your thoughts about? This is a very complicated problem he's dealing with. I mean, they're,
19:48
they're, they're at the end of the, uh, the train line with everybody doing surgery beforehand, handling them and with back pain. That's really complicated. What is, what's your Yeah, well, I
19:58
guess my.
20:02
You know, when you see, we see these patients with multiple surgeries and still with back pain, we sometimes pause a bit just to try to confirm that the pain is in fact related to some anatomic
20:12
problem, you know, be it the infection or axial pain or a non-fusion. 'Cause if not, you know, some of these patients may actually benefit from non-surgical treatment. There's a new paper that
20:26
came out a couple years ago that showed some benefit of high-frequency spinal cord simulation for back pain in a small select group of patients with failed back syndrome. So,
20:42
you know, I would certainly consider - I don't know if that technology is available widely in Nigeria, but that's one thing that we would consider, you know, send them to a pain management
20:54
specialist to see if there may be some non-operative treatment available. Unless you can clearly identify, you know, a reason for the pain, if it's a, if it's non fusion flexion extension viewers
21:05
show that the fusion didn't take, then it makes sense to go ahead and revise if, you know, there's an ongoing infection treat that medically. But that's the one thing that I would kind of throwing
21:16
to the mix is the non surgical treatment of if it was just purely bad name
21:27
Go ahead, Jim. How does everybody treat infection and spine with previous implants is that a reasonable question strata. Well, I think that's, I think that's a good question. And now I was just
21:41
going to ask, raise the prospect of a partially treated infection And so it, in a situation like this is important to, to do an intraoperative culture and follow up on it and, and then make your
21:56
adjustments with, with any body management based.
22:02
on that. Then the other thing is whether this could be
22:06
an end to land infection that doesn't manifest with gross peer lands, but could be something like staff epidermitters that could present like
22:24
that. So that would be, those are a couple of things that would be concerned about. And then the other issue is, I think there was mention of using hydroxyapatite. Is that correct, Dr. Oh, did
22:39
you use hydroxyapatite and just the
22:44
concern about that?
22:48
Yeah, I'm on infection. Yeah. Yes. Yes, we try drugs the appetite because we don't differentiate and we're just to get for solar transfusion, which sounds really hard to extensive laminectomy,
22:57
so we didn't want to take more. from the patient. So what is hydroxyapatite? Actually in trouble we didn't see any active evidence of infection. Well let's maybe perhaps like you said an indolent
23:08
infection. There was no active evidence of infection. That's why we decided to use hydroxyapatite to achieve postodontal fusion for the patient. Did you obtain intraoperative cultures? Yes we did,
23:20
that time it was, it didn't you, it was steroid because with your heart. Okay, okay.
23:28
Wow. Jay, did you, yeah did you hear me Jay?
23:35
Dr. Morgan, you're muted right now but please comment. How about now? Can you hear me now? Yes. Good, good. Sorry it was on call so I'm getting a little bit late. Dr. Oh, did you fuse down
23:49
the L5 S1? No, no. And did you L1 to L5? Did you do any
23:59
to see whether L5-S1 might be the source of pain. No, we did not. 'Cause that's one source. And another source that I found in patients that I've treated a long time and haven't been able to
24:12
figure out their pain sources, SI joints. So L5-S1 oftentimes, if you have a long fusion segment above that area will give you pain. And in addition, you may get some pain from the SI joints,
24:27
which may not be diagnosed And I used to not believe in SI joint fusion, but it's been very helpful in some patients who've had some chronic low back pain, just my thoughts from seeing those films.
24:39
Okay, NEM, do you see a lot of spine cases? And do they see a lot in
24:47
Kenya? Oh, thanks so much. Why don't I get Dr. Michael Magoja? So my god, my god, my god is in this call. And he's the one who is currently in charge of the residence where he used to be, Dr.
25:05
Magoja, are you able to make a comment? Oh, sorry, just a point of clarification. I missed the last question. It was about use of antibiotics or what is available. No, the issue here,
25:20
basically, we're just discussing spandrel instrumentation, the relevance of spandrel instrumentation
25:28
in sub-Saharan Africa and the challenges we face, especially in issues of infection, following the spandrel instrumentation and whether we should remove the implants when instrumentation occurs.
25:43
And maybe what you could comment is how often do we do spandrel instrumentation and the challenges we face on spandrel instrumentation in our setup and the fact that patients have to buy it. the
25:60
implants. So before we do the surgeries and
26:05
basically that takes a bit of time. We share this work with the orthopedic colleagues. And probably I would say orthopedic colleagues maybe do most of this work more than us. But maybe Dr. Magoel
26:18
could just give a general outline. And I also noticed in this call there quite a number of my colleagues from Nairobi from Kenya who could also give their views about this. Thank you.
26:33
Thank you for the chance to comment Professor. I think you've mentioned it. The first thing to note is we have about two or three suppliers with wildly varying price ranges. We don't have the
26:45
companies here specifically, but we have brokers for them. On a lighter note instrumentation is one of the higher charged things, and we think that might have something to do with taxation of the
26:57
instrumentation itself. As President Rombia said at the Kinesse National Hospital, the spine discipline is divided into two. And it is true, orthopedics does take the bulk of the instrumentation.
27:10
However, for many, what we call, quote unquote, complex instrumentations, we do them either in concept or alone. We do most of the upper cervical procedures. With regards to instrumentation,
27:25
all of the things are available locally I need to be clear all the way from artificial discs to self-attaining plates, holding cages are available. So we have a wide gamut. In the public hospital,
27:42
we do get some subsidies and we stick with most of the traditional or all their implants. So just traditional plates and screws are available in the private sector. Like I said, we can go all the
27:54
way up So the residents can attest and I'm sure my colleagues can attest that. We have to keep following up with the trainings about one to a year. And we do have a link via the university with OA
28:10
through the Department of Surgery, sorry with AO, sorry, through the Department of Surgery. So through that, we are part of the Middle East and Africa region. And we do have regular trainings
28:22
with the students. So we are improving, everything is available, but standardization is not, is the short answer. That's the answer part number two. Part number one. Regadding, changing
28:35
implementation dependent on infection. I would say it would depend on the degree of infection.
28:41
For things like acute osteomyelitis, if stability is maintained within the spine, there's no migration or movement to the spine loosening of the screws, then that is fine. We don't really remove
28:54
most of the time We also have access to things like bone cement. If you have a transient infection and you find that the construct is a bit loose, depending on the type of construction we're doing,
29:06
you might just go back in and inject some bone cement there, make sure that it holds. Use some fluoroscopy to check. So you don't normally have to review the whole construct. That's a small
29:18
comment that I would give. Of course, in immunocompromised patients, we do completely review the constructs
29:27
I think it's a long question, but I think that's the shortest answer I could give. I defer to my colleagues. Thank you. Okay. What about Dr. Bell Mootisso? Dr. Mootisso is the one who
29:37
presented last week and he works at the Armed Forces hospitals. Dr. Mootisso, are
29:44
you able to give your comments on this, please?
29:50
Nice to see him Thank you,
29:55
I thank you professor for Happy
29:58
uh for this opportunity to share um uh we do quite a number of uh of uh spine surgery and um
30:11
uh i would say um for the for the generative spine and especially number which is a topic of discussion today uh you know uh the rate at which we do fusion and the rate at which we do not do fusion
30:27
would probably be 50-15 um and therefore we also see uh the complications that come with fusion like presented here uh also quite common
30:44
um uh and some of them include in infection um
30:54
I think which is more prevalent in this in this in this part of the world
30:60
But in terms of instrumentation, I think we are able to do the
31:07
whole spectrum that involves the number of spines stabilization. Yeah, I think this
31:17
would be my comments on this, and this I think is a very relevant discussion for us, because the more, I think we are doing more and more spines and therefore we also see more complications as we
31:31
go on, and therefore this will help us to at least make better decisions for the patients. Thank you. Okay. Thanks. Thank you very much. Ali, you had a, you had a comment or question? Yes.
31:46
Thank you very much. Good morning and good afternoon. Everybody since it's the topic of the spine, I just want to share something that happened in United States, about 150 patients were
31:58
instrumented. for the back injury or the spine injury. And the instrumentation came from East Asia, and they were all fake, and they were broken, broken screws, broken all the metals they used.
32:12
And if we got involved, and apparently the hospitals, to make a cheap deal, they got these instruments from these companies outside the United States And believe it or not, 150 patients are
32:29
suffering, and those surgeons and the hospitals were investigated. The only comment I have for you, don't let these groups to sell the fake instruments for your patient in Africa. And fortunately,
32:43
there are bad people around the world, and they don't care for the patient. Since you are doing such a great job to save the life of the patient, please don't let these fake instruments to come to
32:56
your country in Africa. That's the only comment I have. and thank you very much for all these presentation. I think Mike has got a question, Strada. Yes, yes, please Dr. Magal.
33:11
Thank you so much. I want to associate myself with the comments of the previous speaker. I agree with you, Professor. That adds one of the issues we have with working locally due to the lack of
33:23
standardization and since it's the brokers, it behooves the surgeon themselves to study the implants and decide the one that we can use. Interestingly, what you said is sometimes we have an issue
33:36
of understanding. Patients might just want to pay for the most expensive, even though it's not. So it just adds a new dimension. And we don't get this during training specifically. Afterwards,
33:47
we have to do exactly what you're doing, the due diligence. And that happens about every six to eight months unless you get a favorite broker who has been working for a long period of time And that,
33:57
of course, has a cost implementation. but thank you for highlighting that.
34:01
Thank you, Dr. Mago. I had another comment that has been in the back of my mind. You know, in this case, there was quite a number of years since the previous surgery. And it again, it raises
34:18
the question of an indoline infection, and specifically about propiony bacterium acne, which can be very slow and can be
34:28
difficult to isolate sometimes. You just have to watch the cultures for quite some time. So I just wanted to make mention of that prospect. Dr. Cobb, what's your thoughts
34:41
from your country? Do you see a lot of spines, or is this a common problem?
34:52
Dr. Kaaba, Samuel Kaaba. Yeah, we've actually do the same as my career. And we see a lot of trauma, especially spine.
35:06
We do a lot of instrumentation. The first thing I would just, the beginning I wanted to ask a question to know how the patient is very known, but it's important for me. How is the patient and the
35:16
strategies? I think he said he's still having back pain. He was still not satisfied and
35:24
have persistent low back pain.
35:28
Alvin, you said you see these cases. What do you do for me? Sorry, sorry, I just had a general question to the presenter and to all of us.
35:40
Please go ahead. Supposing that this case had been performed via minimal incentive set for the first time, What would have been the way for my whole life? in again move the screws via minimal
35:51
invasive surgery and go in again do the same or we would have done open surgery as for those who have experienced with that.
36:02
Yes thank you very much for that question. I think a minimally invasive spine surgery
36:09
well it's quite really minimal sometimes one person has had minimally invasive spine surgery and she comes with a field back surgery. I think it's better to come back to open let's go back to open
36:20
because sometimes minimally invasive spine may not be able to address some of the challenges involved
36:27
in the pain generators that are not there in this spine. So maybe better to come back to to open to open surgery if you have this case swelling are dealing with infection in need to resource control
36:40
and all that need to do to a thorough wash out. I think it may be be better at going back to open if this agent has further minimally this is fine surgery previously. I don't have experience with
36:50
that, but that is what I feel.
36:54
Alvin, you mentioned a little bit about seeing this in your country. How do you treat it?
37:01
Thank you. So most often I usually discuss with my mentors from Ghana and at times we should have managed them conservatively and if there
37:10
are some cases
37:20
that we need sprues remover, we need to identify what kind of
37:23
screws were used, which mark, and I usually discuss with some of my mentors from Ghana. But I have a question. If there was no infection
37:36
regarding the feedback syndrome, is there a role for
37:42
epidural steroid injection that is going by the Sacra home? Going through the saccharide, the saccharide hyattus. for that because I was just going through the images looking at I think there is
37:54
the instrumentation from L1 to L5. So
37:59
is there a role in the absence of infection?
38:05
Yes, there's a role for
38:09
conservative management, spine injection, especially when there is no infection, there's a role for that because the more you approach studies, the more you operate, the less likelihood of a good
38:19
outcome. So it will be worthwhile to consider all those and spinal injections in order to achieve pain relief. So there's a very big role here.
38:29
Yeah, I was just one comment. I would be cautious about epidural steroid injection in pranic pain. I think the data is that spine injection. Yeah, for acute back pain, epidural steroid
38:45
injections might be affected 50 of the time and half of those can be attributed to placebo effects. So for chronic low back pain, that'd be cautious about epidural steroid injection. Dr. Allianne
39:03
brought up the prospect of spinal cord stimulation. I wanted to ask the neurosurgeons in Africa, is what is the status of spinal cord stimulation in Africa? Is that a viable option? I know those
39:18
devices can be quite expensive, but so is spinal instrumentation.
39:25
Yes, thank you for the question. And the status of spinal cord stimulation in our country, especially Nigeria,
39:34
is there's no much place for it now. It's what we read about in the books, what we see when we travel abroad. But for now, we don't do spinal cord stimulation
39:46
It's not a very big technology. I just think the challenge might be the cost and the willingness of the neurosurgery community to imbibe new armies of managing and blowback pain. So for now, we're
39:58
not doing it. I don't think there's any sense in Nigeria that those spinal cord stimulation.
40:04
Thank you for that. What are the experiences elsewhere, Ghana,
40:11
Kenya? Well, in Kenya, I think we need to appreciate that Spinal cord stimulation comes with the speciality itself. It's a pain management and functional neurosurgery. Now, those are aspects of
40:26
neurosurgery which haven't really developed very much in Kenya. So pain management at the current moment, most majority of it is really done by our colleague in anesthesia. And spinal cord
40:41
stimulation in Kenya, We haven't at all really established that. you know, as a form of management in like, let's say, dispassioned with a failed back surgery syndrome, we haven't really
40:56
established that. But as I said, it's because areas that specialty or pain management and functional surgery hasn't developed very much in this part of the world. I know, I know in, I was in Cape
41:12
Town last year and it's now when it's starting to pick up. So if areas like Cape Town, which have been very, very well developed as far as neurosurgery is concerned, it's only like, let's say the
41:27
last five years, or, you know, when they've started picking that area of functional neurosurgery and pain management, then, you know,
41:36
areas like Kenya, which, you know, we're very much behind as far as South Africa is concerned This will take a bit of time for us before we reach that level. Thank you. Thank you. Thank you.
41:49
How do you treat this in the Congo? Well, I don't think this will be very much different in DRC in Congo, because in terms of neurosagerie, they're relatively coming up now. So it's hardly, I
41:59
think they're still, it's in
42:08
the infancy stages. Did you have a - Just to make a comment on this
42:15
Well, fortunately, when it comes to this distribution issue and DBS, we really have a zero situation within the continent. I have personally engaged electronics when it comes to DBS and spinal
42:29
cord stimulation, and the post implication is quite alarming. And
42:37
the forms that I had to feel were so many and then a number
42:44
of specialties that we're searching for, neurosurgery from. neurology from the program is from the physiotherapy. I mean, especially when you look at the conditions, there were too many, we have
42:56
only been they're going to try one case. And even that, getting the items from South Africa was the trouble because they said they were not the items that have been formally approved by the FDA. So
43:10
we had to use
43:13
different things to talk to the FDA, but the single case, you can use that
43:21
too. But the application is one of the issues. And then the development of other specialties, especially the technology is in the facility. So there is a long way to go in the - Sam, did you have
43:35
one more case or is this the case that you want to -
43:38
Thank you. I was going to draw attention to that. We had the second case to present. Let's do that And I don't know what I say, I stay a time for that. If there is, then we'll come proceed with
43:48
that. I was hoping now this discussion will take place after we presented the two cases because the theme was for the same thing, the problem of instrumentation and the continent. Okay, well, sir,
44:01
let's go ahead and do their presentation and let's be expeditious about it. And look, are you
44:07
there? Yes, yes, bro. Please get on with it. Thank you.
44:13
By the way, the name on the screen is not the best present present. Oh, please present present it, but I'm seeing a pada on the screen. There we go. Okay. Yeah, that's fine. While he's doing
44:26
that, I'd say the first case you presented, Sam, was complicated. What we've seen is it's complicated everywhere in the world. Yes. You're treating backwards, which is difficult in the first
44:40
place and the second place. It's, I mean, there's no hope for anything, And so it's really a very difficult river. Well, it's a three-year-old right-hand man who presented with a mix of four
44:54
fall and
44:57
still this and observed three days' duration. He was
45:00
passing by an opposite field when a block of
45:05
public block fell from an opposite field and fell on his head. He fell on realize equal moment is then lower things. He was initially neutral The private hospital today, I had a insurance
45:15
association before he came to our office. On assessments, he was asset, I think, so completes Savaka's financial injury with C6 and the logic and level. And he came on the fourth day of surgery.
45:30
The MRI showed spinal cord eating up to C2. C6
45:38
disturbance, contour in this case is matromatic, this rupture and then and then.
45:44
have to proceed on the
45:47
government's hypothesis. City also corroborated the same. We rushed to do sorry for the fox bed following trauma. We had an ACDF with components with zero missing technique. And then after ACDF,
46:03
who was extubated and thanks to the ICU. And one day post-doc we developed.
46:07
And we see the images, and we see the images, please, of this patient I thought I was giving a summary.
46:15
I thought I was giving a summary, sorry.
46:19
All right.
46:21
This is the image of the patient. This is the top-up image, this is the situation. 666-7, it's fine, I apologize, I want to see 3D image. This is the spinal MRI,
46:34
showing a 666-7, traumatic disc rupture, and then assembly for the demo, I will see you in the next video.
46:43
as well as co-compression on top of the road. They also are selling at the same equipment. That was of '66 HRS, I was first trying to build two, as well as '66 was when he was under the end of
46:53
this, SEA. Marine, I was first trying to control. He had '66, '7, Maj. SEA. within it. He was a preparer, that is three days post into it. Intraprene is a full of soft tissue swelling with
47:04
'66, '7, and from the status, I was still the swear to extract the air that I came. And properly, he had an opportunity to make movement on anesthesia, on the anesthesia, with head straps.
47:17
This was how I attempted to talk about an anesthesia. He was a stuberter, and I started intensive care unit. He had to compromise the expression one day post-op with decreased air entraprene, ABG
47:24
showed a complexity and expression as usage in a pH of 725. It says, Stating immediate integration and mechanical integration, less than a unit.
47:32
His post-op recovery was complicated by a current chest infection, right-right infection of ouchy was too tight He also had the latest application for this post-op recovery. So that's him, OXIMA.
47:44
This is the post-op city showing the SCDF Hispanic protection issue with your profile soon. We remain on our side of the mode of mechanical ventilation that's quite multiple attempts to lead in to
47:56
the post-contaneous mode. About two weeks post-op, we were able to upgrade some improvement by initiating spontaneous ventilation that was on campus or sustainability over a considerable period.
47:58
The
48:05
question that I think
48:07
is about the general dependent status of the patient. Our family request was under the vanishing constraints which was referred to another national facility. He had to
48:16
prove feeling that a total of seven weeks post-op to facilitate feeling. His current logic level is C4,
48:24
which is also 15 and in touch higher-cerecra functions. His current is seven months on mechanical, ventilator, and has still all the details at times as women. What are the management challenges?
48:35
Long term mechanical ventilation and four prospects are only in complete traumatic science and technology level at CFO in a long month. Then, any postulate surgery have given time for us to
48:53
stabilize this patient and possibly avoid ascending and for them eating. I want any points here. We would have delayed, given the economy that we noted, I was off the seat, so we would have
49:00
delayed more so it would have been in this patient, allow this patient to stabilize. Then, he had been anesthesia to avoid more second risk and opportunity with the patient and surgery To avoid and
49:09
address it, we didn't manage chest defections and consider any tractors to be, despite ACDF work which were indicated or anticipated. Thank you.
49:23
So, our challenge here is a young man who is fully conscious, has been ventilator dependent of course, or several months, following him from this panel, I apologize to him, but the sensation of
49:34
the arm on the throat of it, so.
49:41
In South China, Africa is a rich and rich and rich person. For example, I don't know what for face elsewhere. I'm sure it's going to be a problem I won't worry about. This is the
49:50
same thing you want. He is fully conscious, has the right to answer. We have the Seattle problem, getting it optimally. And his neurologic level still remains simple. Emissionally, it was 6-6,
50:02
but it ascended to CFO. That's here in life, it's a challenge in knowledge and research. So one day, the next one is a quality So I'll make some contributions and see how we can mix some progress
50:12
in managing this research. That is tasking our resources.
50:18
Thank you. Thank you.
50:22
So this is a challenging problem anywhere.
50:27
I think the greatest prognostic
50:32
indicator was that he was Asia A on presentation And you may mention of the MRI scan. And I think you said that there was already indication of edema ascending up to C2 at that time. So
50:51
I think regardless of the timing of surgery, you probably would have had that evolution over a few days. I remember when I was in residency training in the '80s, we
51:05
operated on people with cervical spine injury in the middle of the night, as soon as possible, emergently, but the thought was
51:15
that it didn't make much of a difference. So there was more
51:21
approach of delaying surgery. And now the pendulum has been swinging back to doing early surgery, again, with some indication being that early surgery may make a difference with neurologic outcome
51:37
But but the problem is In this case is that the patient was Asia A on presentation, I think.
51:46
I Jay Morgan, do you have any thoughts about this? I would agree with this. I think the other thing is that the patient presented, it seems like three days after the injury. So you're getting to
51:59
them after, if there is a time to get to them immediately, um, that's kind of passed. And that that's, you know, not, not physician mediated. Uh, so I think this is just one of those sad
52:13
cases when these things happen. Certainly we've all seen it. And it looked like on the MRI scan, the edema was all the way up to C2 already. Um, so whenever happened after his injury or with his
52:25
injury, he had extensive core edema and, uh, this is, you know, probably patient disease.
52:35
I agree. Um, my, uh, this is Dr. Allen. Um, I think, you know, timing probably won't make any difference here given how extensive the injury is, I do have one question and the question is,
52:46
was there any attempt to correct it looks like they had a spondylist thesis, maybe a perch percet or jump percet. I'm just wondering if there was any attempt to reduce that
52:58
interactively or not
53:01
Yes, we did attempt to use that knowledge structure, use that knowledge structure to try and reduce it, but that was the best we could then get promoted is from grade two to grade one
53:12
That can be the challenge with these cases, especially if there's a fracture of the facet joint that an anterior approach may not be sufficient to fully reduce the
53:32
deformity And my preference has always been to do it anteriorly. if I can, and would even do manipulation under anesthesia to get a reduction. But if that's not feasible, then
53:49
bite the bullet and flip the patient over and do a posterior approach to effect the reduction before stabilization.
54:03
Well, Sam, you presented two almost impossible cases, which are impossible everywhere in the world. And I don't think anybody has any suggestions to do differently or better than
54:21
you did. Just one is just stressed to see this because you can't do much to help them
54:28
Back pain is a terrible problem everywhere. And the question is, is
54:36
the back pain, and this man looks like he was okay for a number of years until he had the surgery of the first case. But instead of a failed back surgery, it was a failed surgeon's decision process.
54:49
So these are very complicated cases. I don't
54:54
think we have any bright ideas for you, Sam.
54:59
Thank you. So there's there's a question that Ali put in the chat asking about whether traction was used intra-operative. I know there was mention of Gardner Wells' tongue's main place, and
55:11
traction being used, was that was that maintained throughout the case? The
55:17
traction. Yes, the instruction was maintained throughout the case, to achieve a reduction But we couldn't reduce more than combating the two to grade one. We tried, we had to fix it at that level.
55:18
No, traction was used. Okay, is there any other discussion? Because we should go on to Cargill's presentation, I think. Yes, yes. James,
55:42
thank you very much. Those are other three cases you presented last week, and this week you're extremely challenging problems Very difficult, and nobody's got any better ideas than you've got, so
55:56
you're doing great.
55:59
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