4747To improve the life expectancy of Nigerians:To improve the life expectancy of Nigerians:

Improve health care delivery system- Improve health care delivery system- DoctorsDoctorsEducate the public on health matters- Educate the public on health matters- DoctorsDoctors

Improve social services and quality of life- Improve social services and quality of life- GovtGovt

The Sid Marks principle:The Sid Marks principle:

Each patient has something to teach usEach patient has something to teach usUse every opportunity to learn and to teachUse every opportunity to learn and to teach

my principles:my principles:

Never make a mistakes twiceNever make a mistakes twiceMy surgery results matter My surgery results matter

Anterior decompression, fusion and Anterior decompression, fusion and plating in cervical spine injury: plating in cervical spine injury:

Early experience in Abuja, NigeriaEarly experience in Abuja, Nigeria

Biodun Ogungbo and Felix OgedegbeBiodun Ogungbo and Felix OgedegbeCedarcrest Hospital, Abuja

Materials and Method Materials and Method • Spinal cord injured patients• Admitted under a single neurosurgeon• Operated via anterior cervical decompression• From August 2009 to date• Frankel grading pre and post op (ABCDE)• Bathel Index for outcome (ADL)

– Dependent– Independent

LUCKY PATIENT

UNLUCKY PATIENT

HEROIC OR STUPID SURGEON

FRACTURE DISCLOCATION

TI/T2

Results Results MRI scans in all patientsMRI scans in all patientsEarly operation in majorityEarly operation in majorityNo intra-operative complicationsNo intra-operative complicationsSafe operations with minimum Safe operations with minimum equipmentequipment2 patients were irreducible2 patients were irreducible

Irreducible dislocation but cord well decompressed

Courtesy of Implants international, Thornaby, UK

INTRAOPERATIVE IMAGE

POST-OPERATIVE IMAGE WITH BONE GRAFT

POST-OPERATIVE IMAGE WITH A CAGE

BUY ONE, GET ONE FREE OPERATION

20 patients over the year

Of the 18 patients who were operated, 4 patients died within a short period. 7 patients have made a full recovery and 7 remain fully dependent. Two patients who were initially paralyzed walked out of hospital.

ConclusionsConclusionsEarly referral for surgery is crucial Operations are safe in AbujaCervical traction is done very carefully Early deaths due to poor intensive care Only 2 of the 7 dependent quadriplegic patients are reintegrated back into the societyRehabilitation centres are needed

Surgical management for cervical Surgical management for cervical spondylotic myelopathy: spondylotic myelopathy:

Early results in AbujaEarly results in Abuja

Biodun Ogungbo MBBS, FRCS, FRCS (SN), MSc

Background Cervical spondylotic myelopathy (CSM) is a common cause of spinal dysfunction in the elderly.

It appears to occur in a much younger age group in Nigeria.

However it is frequently not diagnosed early due to the paucity of MRI scans. When diagnosed, many are treated with steroidssteroids and conservatively.

Therefore, patients present late for surgical intervention.

ObjectivesWe present a review of patients with cervical spondylotic myelopathy.

The early results of surgical management in 6 patients are presented to highlight the safety of operative intervention.

Methods The medical reports of all patients with CSM were evaluated.

The clinical presentation, imaging and operative intervention are carefully discussed to highlight the learning points.

The surgical pathology and approach adopted for each patient are clarified.

Results Six patients have undergone surgical management for CSM since August 2009.

Five of the patients were quadriplegic at the time of the operation.

They were unable to feed themselves or perform activities of daily living without assistance.

Results Three patients underwent anterior cervical discectomy and fusion and 3 had cervical laminectomy performed.

Five patients improved significantly post operatively with sustained neurological improvement over 6 months of the operation.

There was one death due to pulmonary embolism 3 weeks after surgery.

Case based discussions: 68 year old female, Hypertensive and Diabetic. Diabetes is poorly controlled.She presented with 6 months of progressive numbness in the hands and feet. Glove and stocking distribution.There are no other symptoms.

Clinically, she has no motor deficits in all 4 limbs but has hyper reflexia. Objective sensory change was mostly in C7/C8 dermatomes bilaterally.Bowel and bladder function and walking were satisfactory.

MRI SCAN SAGITTAL T2W

Surgery performed was an anterior cervical discectomy and fusion using the patients’ iliac bone.

I decided to fuse at two levels C4/C5 and C5/C6 though the main focus was really to do a good decompression of the space behind the C5/C6 disc, which is the site of maximal compression on the MRI scan.

POST OPERATIVE X-RAY

Post operative image

The patient had an ACDF at C4/C5 and C5/C6. The kyphosis is corrected and hopefully will be maintained until fusion in the hard collar.

She will wear the collar for 3 months.

Clinically she recovered well from surgery and has been discharged home.

Her neurology has improved significantly with better sensation and increase in dexterity in the fingers.

CERVICAL SPONDYLOTIC MYELOPATHY

P. E. 65 years oldHe presented with a long history of immobility and progressive deterioration in his level of function. Unable to feed himself, turn in bed or do any activities of daily living. He had been bed bound for about a month. He had clear signs of cervical myelopathy

ConclusionThe management of moderate & severe CSM is surgical.

There is no role for conservative management unless the patient is medically unfit for surgical intervention or there are no surgical lesions. NO ROLE FOR STEROIDS

Operation can be performed safely from either an anterior or posterior approach.

Early sustained recovery has been encouraging in our small series.

Cauda equina syndrome

The anatomyThe clinical presentationCauses of CESTreatmentControversiesComments and opinions

Cauda Equina Syndrome

• A clinical syndrome due to compression of lumbo-sacral spinal nerves

• Clinically, radicular pain, uni or bilateral• Motor weakness in variable myotomes and

sensory loss• Perineal numbness• Loss of anal tone• Loss of bladder function leading to retention• Impotence and sexual dysfunction

Complete or incomplete CES

• Complete CES– Objective loss of perineal sensation– Bladder retention– Patulous anus

• Incomplete– Altered sensation, loss of desire to void and poor

stream

Lumbar MRI (sagittal view)

Lumbar MRI (axial view)

Cauda equina syndrome

The anatomyThe clinical presentations1.Case of Miss X2. Case of Mr YCauses of CESTreatmentControversiesComments and opinions

Cauda equina syndrome

The anatomyThe clinical presentations1. Case of Miss X

2.Case of Mr YCauses of CESTreatmentControversiesComments and opinions

Cauda equina syndrome

The anatomyThe clinical presentation

Causes of CESTreatmentControversiesComments and opinions

Disc prolapse

Spinal tumour

Spinal tumour

Spinal infection (discitis, abscess)

Cauda equina syndrome can be caused by anything which compresses the

lumbo-sacral nerves (the cauda equina)

Big disc prolapses in young peopleTumours which can be primary or metastaticInfection including discitis and spinal abscessesTrauma bone fragments and blood clotsLigamentous hypertrophy in elderly with canal stenosis

Patients require decompression.Remove whatever is causing the

cauda equina compression.This will stop further damage to

the neural tissue and allow healing to commence.

The operation

Cauda equina syndrome Cauda equina syndrome controversy: controversy:

Does the timing of surgery influence outcome?

NV Todd, British JIn incomplete lesion, timing of

surgery is important. Early better than late

In a complete lesion, early surgery probably of no benefit

Meta analysis

• 6 clinical studies evaluated. These papers reported the effect of early and late surgery on outcome

• Meta analysis demonstrates that patients treated earlier than 24 hours after CES onset were more likely to recover bladder function (p=0.03)

• Also, patients treated within 48 hours were better than later (p=0.005)

• In effect, concluded that the timing of surgery does influence outcome.

Sources of litigation:Sources of litigation:Delay by general practitioner

Delay by radiologistDelay by surgeon

Surgical complications

My pregnant patient

Operate early for a happy surgeon and hopefully a happy patient

Happiness is a journey, Happiness is a journey, not a destination. not a destination.

So work like you don't So work like you don't need money, and dance need money, and dance like no one's watching. like no one's watching.