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SNI, Surgical and Rology International, and SNI Digital Innovations and Learning in association with the Sub-Saharan African Neurosurgeons presenting another in the monthly series of Sub-Saharan
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Africa
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International Neurosurgery Grand Rounds The general topic of the Grand Rounds are global solutions to clinical challenges in neurosurgery. The moderators are Estrada Bernard and James Osmond.
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This Grand Rounds was held on Sunday, October 6, 2024. Instrumentation in spine surgery and decision-making challenges in Sub-Saharan Africa with a case illustration on Lumbus sacral spondyloptosis.
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The talk will be given by Sam O'Hegelbaum, who's the
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neurosurgeon in chief and founder of the Memphis Hospital of Neurosurgery and the CEO of that hospital and the former president of the African Federation of Neurosurgical Societies, also a professor
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at the University of Nigeria where he was dean and deputy vice chancellor, all in a NUGO, Nigeria. In addition to Dr. Ojigobam, Professor
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Nanbushi, Professor Okwan Dulu and Professor Diogolo, all neurosurgeons from the Memphis Hospital and NUGO, John Nigeria.
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All right, thank you very much. The topic of our presentation, I'm Samuel O'Hebulam from Memphis Hospital in Edible, and I'm here with the members of my team, and we want to discuss spandling
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instrumentation and decision-making problem in South Carolina, Africa, as simplified in our experience at Enubu. The spand surgery is an increasing
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problem.
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All over the world is increasing in volume, and Africa is gradually keen into this expansion
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Instrumentation is also increasing in volume, and it's not surprising because with Asian population
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and increasing trauma incidence, the
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instrumentation has become a major surgical procedure that is brain and has a reasonable volume. We have about 27 of our workload, surgical workload,
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and
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many of them are instrumentation. It's our experience here, and this will be illustrated with two cases, one that is complex trauma case, and another one degenerative spine disease in the Lumber
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region. We hope that we can ask us, please, put some of the questions that we encounter on our daily practice.
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Who requires implant? We should ask ourselves. And what they said, mostly trauma patients degenerative spine disease, some spinal tumors after surgery, and congenital lesions.
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require assistance or follow-up surgery with instrumentation. But what are the risks and problems? These are the things that influence decision-making. And seizure considerations, infection,
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hardware problems, implant migration after surgery,
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spinal cord injury during difficult instrumentation surgery, sexual dysfunction can occur first, appropriately.
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The abdominal effect has been mentioned and discussed extensively because of adjacent-level degeneration that occurs after fixation of the spine. And metallosis, the
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toxic effect of metals released into the blood from implants. These are problems that confront the surgeon, because it's not just putting the screws and the implants. you have to manage these
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complications if they occur.
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That was, in South-Saharan Africa, the problem is compounded by poverty. We don't have the resources. And we know the cost of response implant is rising, but the day as new instrumentation is
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introduced in the market, the prices escalate. So patients cannot afford it. And many a time we have to struggle to give the patient a fair decision or advice on what to do, the way instrument or
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not. And in our center, we had to navigate around this problem even to the extent of offering non-instrumental surgery as we highlighted in the cervical region that we can do floating laminoplasty
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as an alternative to instrumentation And this is offered to some patients in select circumstances. particularly those who can't afford more expensive surgical options. We also, in the Lumbar region,
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offer a lot of hemelomidectomy and spinal
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nerve root decompression. So let us listen to my colleagues who present two cases and this and there.
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The first person is Dr. Dona Dovolo, who will present a case of complex Bumbar
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sacrum. Shoma case, thank you very much. All right, good evening everyone from Nigeria. Good morning, good afternoon, wherever you might be. So we will be talking about,
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we'll just be using a case illustration
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on Lumbar sacral and spondyloposis. So like has already been said, We know that's panel instrumentation. surgeries have revolutionized spine surgeries. It helps in early mobilization of patients,
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as well as eating and achieving an earlier cure when compared to conservative management. However, when dealing with complex spine surgeries, which requires fermentation, it's quite challenging or
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quite difficult to rely on already existing or already established on protocols for treatments of such conditions. And as decision-making for instrumentation in these complex spine cases needs more
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considerations, including experience and peer review. Traumatic lumbosacral spondyloposes, defined as 100 translation of
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the proximal vertebral body of the next one. With neurologic deficits, it's one of the rare pathologies that. present significant decision-making challenges to spinal sergeants. And some of the
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problems are usually encountered with this. Most of these patients present with complex routes here, with CSF leak. And of course, compression of the cardiac quina, which could be informal
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stretching during transactional
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compression itself. And then a lot of them also have associated sacral or pelvic ring fractures with this location. And then the problems of biomechanical instability is something that cannot be
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overlooked in such patients with traumatic
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lobosacrospondyloposes. And so this actually reports our experience within this institution. And the challenges we face in the management of this very rare case of traumatic L5-S1-spondyloposes So
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this was a that one year old lady who presented to the emergency. room with a weakness of both lower limbs of two weeks duration. She was an only strain passenger at the back of his salon car,
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which in an attempt to avoid an oncoming vehicle, a veil of the road and some assaulted several times for coming to a halt. She had transient loss of consciousness and was found unconscious in a
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nearby bushittering. And then she had associated severe low back pain, lower limb weakness with associated sensory deficit. This was post when she recovered consciousness, as well as bisoyantaric
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dysfunction in the form of urinary retention and faecal incontinence. And when associated cranofacial effluxes, seizures, or other comorbidities. She was initially managed at another hospital
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facility about three hours from us for two weeks before referral to our facility. So on your logic examination A neurology of both upper limbs and the brain were essentially normal. Lower limb
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examination reviewed hyperreflexia and hypotonia. And then on examination of the power, the hip flexions were essentially two over five on the right and three over five on the left. Right ankle
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does deflection and plant deflection where zero over five. And then out of the left ankle range between one to two over five I essentially left was at S1, and I think that was part two loss weights,
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absent per annal sensation, global carbonosis reflex was present. An examination of the back revealed the gibbles which had a lumbosacral region with a step deformity. It was tender with
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differential wound with mass associated sinus or discharges. Now, this is the preoperative radiograph of the patient's CT scan and MRI, MRI in CT I'm showing the Spondille up to see star 5 on. S
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one with partial resection of the disk on this side and retropotion on the other side as well as.
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In for your displacement of L five on S one, and the cities can also essentially confirms. Confirms that
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so preoperative city for that should a transverse fracture a fracture and oblique fracture of the left transverse process of L two And then the laminar right out here was also fractured also should a
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committed fracture of S one weeks. By a large file, I'm in a fracture or S one to. So the probability of diagnosis was that of a traumatic L five S one's point, the look to see sweet associated
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complex So the
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problems identified way has already discussed. So this patient had a multidisciplinary care involving neurosurgeons, the other pedic surgeons were also involved, as well as young sociologists. And
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then our peer reviews were done, both from literature and other centers globally. The decision actually hinged on, I would have to offer this patient conservative care or predictive treatment,
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conservative in the sense, this patient had a very severe grid of injury with associated biosphere and direct dysfunction. And then also had a lead presentation, two weeks post injury, which would
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have pointed more towards conservative care. What you need for, to allow for mobilization of these patients, as well as stabilization of the spine, prevent problems of immobilization, actually do
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that towards operative management So this patient was cancelled on the aims of surgery, the possible complications and intraoperativity mutations. And then of course, very important, the
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possibility of recovery of motor functions and sphincter control, which is one of the problems that most of these patients actually seek care for. And then cooperative planning and workup was done
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for these patients. So this I'll get to please four weeks post injury and two weeks post admission to our facility on that general anesthesia and where I post your approach. So the patient had an L5
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facetectomy with reduction of L5-S1 distasis as well as L4-5 and L5-S1 distactomy with alignment of L4 on S1. She also had instrumentation and fusion procedure L4, S1, a mutable diffusion with
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impactor at the logos and ILAC
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bone graft So the,
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so the, so the, The introvert you find is included that of L5S1 from the loop to CC by lateral, L5 facet injuries, left L4 facet injuries, fracture of right L4 pedicool by lateral facet injuries.
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And then she also had a Dural and complex Dural and nerve injuries, some of the nerves were transacted were attempted repair of the Dural So you saw a good last set of about seven and a half hours
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and was likely uneventful. So this is the immediate post-op check CT scan that was not fully patient. Shame proper, screw, placements and alignment. This is an X-ray,
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also confirming that. So post-operative ratio was placed on street bedrests for about six weeks This was to allow for, to maximize the healing of the pelvic fracture as well as. allow for L4 S1
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interval diffusion to survive without any motion. And I'm glad that you see the therapy sessions were comments for her, initially in bed, and then she was subsequently mobilized post six weeks on
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rigid thoracolumba cosets after radiological inflammation of color formation. And she posted up relatively, the recovery was complicated by surgical site infection from a persistent CSF leak. So
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this was jointly managed by the
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with the plastic surgeons. The CSF leak at this stage was managed conservatively. And she had regular one dressing of the SSI. And the vacuum assisted wound management of the SSI was done.
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So at discharge, this was actually nine weeks post surgery And so I discharged the. Lemurology essentially remained the same as the preadmission. And since we had a bi-centering dysfunction,
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rehabilitation was also done on an outpatient basis. So post discharge and during life of law visits, she demonstrated a gradual improvement in the power of her lower limbs. Two months post
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discharge, she could sit out on a wheelchair for longer directions. And about seven months post discharge, she could now ambulate with a Z-man's frame. And some of the months post discharge, she
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could stand on a walk without supports and she had gained continuous of urine. What the flu, bright foot, was your presence. So this is the radiograph at 11 months post surgery when she came for a
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full-up at the clinic. So this is the patient mobilizing on the Z-man's frame.
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So the right flail foot seal
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presents and then this is a patient using walking with the aid of
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walking aid Thank you.
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Okay, and then, so this is the patient walking without supports this stage. So we can see the flow of foods of CO presence, and then moving up and down a flight of stairs
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Okay, so now for the main points, what were the challenges in terms of decision making for instrumentation? Should we have instrumented with the aim of just realignment or just to achieve stability
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without restoration
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of balance in this patient? And then
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for patient with neurologic deficits, do we instrument or do we not instrument? And this is hinged on
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aligning to objectives, also hook off functional recovery against that of just achieving a good cosmetic outcome. And then in our setting, there's also the challenge of availability of
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instrumentation, the momentum to carry out some of these procedures, especially the ones that involve some intricacies The topic told me, would it have been necessary? in settings that would have
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the instruments to that in our setting. We just have to do the compare coming to be able to achieve adequate reduction and alignment for these patients. And then of course, delays in presentation
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should instrumentation still go on when nature is already initiating the healing process. And then what are we going to achieve going into carry out this reduction in the face of adhesions? Of
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course, these patients present bedlates. And one of the problems that we anticipated was that of presence of adhesions from these injuries. And then these surgeries are relatively costly. You know,
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setting due to
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challenges with health insurance and most of these patients pay out our pockets So, a lot of the times we have to wait. operative benefit in terms of outcomes against the cost of the surgery itself.
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And then, of course, the consent of access to long-tempo stop rehabilitative and therapy against maximizing benefit for these expensive surgeries. So, what are the take home lessons here?
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So, personally, based on our experience right here, we think that such complex spinal surgery should be individualized, especially when you're looking at it against the backdrop of going for
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either a conservative care or an instrumentation surgery. And then, the decision should be based on reveal of the challenges which we've already highlighted in this lecture. And then, the decision
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should factor in long-term expectations of patients and non-medical outcome against the cost of instrumentation. Thank you very much
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Excellent job Donald.
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Yeah, thank you for your presentation. Congratulations on the management of this very complex case.
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Strada, can we ask Jay, Morgan, Jay, are you still there?
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I would say give people some perspective Jay actually, we met Jay and we went to Henry Ford Hospital. He was on a program, did an outstanding job. He's been in practice in a medium-sized city in
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Nevada and has developed a group of people who are doing practices. And president of the Western Neurosurgical Society and is gonna be the president of the
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Nevada Medical Association in a couple of years. And he's had a very active practice in neurosurgery. Uh, and, uh, and you, you thought that this was, you, from what you said, Jay, that this
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would have been what you would have done in your circumstances. Is that correct?
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Yes.
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We haven't difficulty hearing you, Jay. The resolution isn't very good. We've got to get your new microphone or something. But anyway, we'll get that But we appreciate your involvement. But I
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just wanted to make sure that this is exactly or it's very similar to what you would do in your circumstances. Is that correct? Yes
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Okay. Listen, Donald, this is an excellent job. Sam, terrific. Sam, you probably know Jay because you were together in Detroit, I think. But anyway, it's an excellent, excellent job and a
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very complicated problem. And what you said at the end was true. You have to take a lot of things into consideration. And those are practical. They may not be ideal for everybody, but that's
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practical life. And I think that was your point, Sam.
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I'm sorry, somebody else wants to. Alvin, do you want to make a comment? Do you ever hand up?
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Thank you very much. And I think the case was quite interesting. And I want to say a big thank you to the team from Nigeria. But I just have two questions. Number one, in the presentation, I
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overheard post-operative late, there was CSF leak and the plastic surgeon was cold. So I didn't know whether, because I didn't, I just need to get clarity on that. And then the second question is,
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looking at that high energy
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structure. Even. you have titanium, and then you have cobalt chrome.
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Which material do you want to use for the ropes in order to achieve stabilization? Given the fact that COVID chrome offers exceptional strength and stability. So I didn't know. What do you think,
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Dr. Goulou? Thank you.
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Thank you very much I think the CSF leak had started even before the surgery. You know, it was a very complex injury that stretched both the nerves and the caused complex tear of the Dura. So this
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was a serious problem going into the surgery. Precautions we are taking to try to patch the Dura, but it wasn't very effective So post-operatively, the problem. the leak continued. This was there
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before surgery. And it was good we involved the
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crisis and eventually because the air was achieved, was achieved closure
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of that wound. The second problem was that the head of the ILEX crew was also threatening the putting pressure on the line of the suture So that was another complex reason that the plaxagion in there
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to be involved in managing the wound for us. And then also the risk of saccharosa because the head of the ILEX bone was everything true through the ILEX bone screw was everything through
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the skin at a point. Then coming to the second question about choice of implants Yeah.
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The answer makes it easy here for us because we are restricted to titanium. But I think I acknowledge the
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intrinsic strength in Kuberts, but I don't have enough experience on ground to
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compare between the two. But I know that what it gained is strength. It was all lost in the model properties like
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ability to
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allow intrinsic movement. But also, I haven't said that. We've done
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more than five, up to five level instrumentation, occasionally with titanium rods. What we do, as you saw in this index patient, was that we had to use a crossbar to complete the talk so that the
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coupling effect is
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synergized. I think with that, we haven't had
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problems of. breakage as a result of this.
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Okay. Astrada, any other thoughts? We've got two, three excellent presentations.
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I think our friend from Orlando left. Okay. Yes, he
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had, Dr. Elbaba had an emergency. He sent me a message He had to go because of an emergency call. But I think it's been an excellent discussion. And I appreciate the group from Nigeria sharing.
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Professor Nynn had one. Go ahead, Nynn.
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We have another presentation. I have another more presentation, yes. Yes, we just did two
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Okay, my comment was. After surgery, this patient was immobilized for six weeks. How do they come to that figure of six weeks, that's the question. And then secondly,
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supposing the management was from the onset tailored towards immobilization for six weeks. Then how do we then we know that the results which you have achieved, I know that results which would have
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been achieved if the patient had been immobilized for six weeks. Thank you.
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Yeah, thank you very much. I think this is why we are discussing this case because it's either way you look at it. There is no established protocol that would have addressed the problem But suffice
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to say that the six weeks mobilization was because there was associated complex pelvic fracture
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That the pelvic surgeon needed to also manage. So eventually he recommended that the patient should, despite the non-saccharideal screw to support that patient should be on a bed to achieve a more
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rigid, more secured healing of the perfect fracture. Then that on our own side was also adopted because the autologous bone graft we did because L5 was completely
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lost in the process of this realignment. So it was L4 to S1 instrumentation really that was done with packing of autologous bone from the patient into the bed between L4 and S1. So to achieve a,
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there was argument that
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because it's the first time we were having this experience any mobilization may not allow
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the autologous bond that was packed there to effectively
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form colors being wiped and retained. So, to us, it was we went to allow this construct to take
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before mobilization. But the only argument, the only advantage about surgery and demolition was that we were able to achieve
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stability, such to balance was restored. And this was the basis for the patient recovering capacity to
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walk that was achieved today.
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Thank
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you. Sam, I wonder if we could ask you to, I know you spent a lot of time preparing for another case, but could we put you first up on the next, our next Grand Rounds, 'cause we wanna give you
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enough time. Do we have your permission to do that?
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That's fine. I agree. I'm just shocked. We really appreciate the effort and your team and what it's done and what you did. Okay, and Ms. Rastrada, can we do that? Yeah, well, I think that's
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great. We'll. Can I make number two, Sam and others? We have a video of that I put up this month on Nancy Epstein talking about post-year approaches to the cervical spine. And we ask many
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questions about what if you don't have instruments, what if you don't have these things? And she discusses practically many of the things that you raised, Sam and Donald, that you implemented in
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Nigeria. And you
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always don't have to have the
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leadist equipment to be able to do a good neurosurgery. And I think you're demonstrated that So it's a video that's up there. Next thing, I'm Nim, is I wanted to tell you that. We have, I guess
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we probably have many, many countries now in Sub-Saharan Africa, they're looking at, as an eye digital, we're over in over 130 countries now, and our projected viewership will be over 20, 000 a
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year. So I think we're doing things that people like. So I just wanted to put that note in. We hope everybody's enjoyed the meeting today I did, I thought I learned a lot. And Strada, do you
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want to say anything here at this point? I think we can wrap it up. I want to remind everybody that this conference meets on the first Sunday of each month. So our next session is on November,
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November 3rd. And we have an interesting lineup, and that will include the remaining presentation
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With that I think we can we can conclude thank thank you all for your Active participation. I think this is is gaining very good momentum Please write us so your comments on how we can do this better
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and we really appreciate that Thank you very much and Australia. Thank you for organizing and arranging all this. They're okay. We'll see you next month We hope you enjoyed this presentation
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