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Uganda Charitable Spine Mission

January 28th-February 8th 2008 Trip Report

http://www.firstgiving.com/UgandaSpineSurgeryMission2008-2009

Trip Report; Uganda Charitable Spine Surgery Mission
Prepared by Bharath Surapaneni & Isador Lieberman January 28th-February 8th 2008
Team; Isador Lieberman MD, Mark Kayanja MD, Selvon St.Clair MD, Adam Rodatt RN, Bharath Surapaneni BA Locations; Mulago Hospital, Mengo Hospital, Katalemwa Cheshire Children’s Home Society Sponsors; Health Volunteers Overseas (Orthopedics Overseas), Scoliosis Research Society (Global Outreach Program) Corporate Sponsors; Medwish Inc, Synthes Spine Inc, Kyphon Inc, Cleveland Clinic Local Physicians Dr. Deo Bitariho (orthopedics-Mbarra), Dr. Malan Nyati (orthopedicsMulago), Dr. Geoffrey Madewo (orthopedics-Mulago), Dr. Fulvio Franchesci (orthopedics Katelemwa & Mengo), Dr. Titus Beyeza (Chief Dept. of Orthopedics -Mulago), Dr. David Snell (anaesthesia registrar, Mengo), Dr. Sara Hodges (anaesthesiology, Mengo) To whom it may concern, The 2008 Uganda Spine Mission Team with gratitude and anticipation for the future, respectfully submit this trip report outlining the accomplishments and details of our recent Spine Surgery Mission. We would like to first acknowledge the support of the many, who with their contribution allowed us to once again accomplish so much. Synthes Inc. provided the full breadth of instruments and implants to allow us to treat the entire spectrum of spine pathology. Kyphon Inc. provided Health Volunteers Overseas with a charitable donation that covered travel and shipping related expenses for the team, as well as patient care related expenses such as the purchase of x-rays, CT scans, analgesic medications and antibiotic medications. The employees of Kyphon Inc. also raised a separate fund to help purchase a generator at some future date. Covidien Energy Based Devices donated a cautery unit and associated supplies. Mr Anibal Morales (CCF) was again resourceful in finding and refurbishing a discarded spinal surgery four-poster frame. Mr Tony Shawan (CCF) repaired and adapted the frame and other tools for our use. Ms Betty Balmat (CCF) and Dr Kris Siemionow (CCF) were instrumental in sourcing discarded linens (sheets, OR drapes, towels, gowns, pillow cases) at the Cleveland Clinic which were then packed and prepared by Mr Mark West’s and Bob Gorta’s (CCF) supply chain team for shipping to Uganda. Mr Rex Taylor sourced a head light generator, which was repaired for use. Ms Mary Kay Reinhardt (CCF) was instrumental in collecting discarded surgical supplies that were suitable for re-use. Medwish Inc. was yet again a source of vital medical equipment which proved indispensable during this mission. Finally, and as always, the staff at HVO and the staff at SRS were dedicated and a pleasure to deal with. The 2008 team consisted of the veterans (IHL & MK) and the rookies (SStC, AD, AR). There was a clear distinction in emotions and anticipation between the two. The veterans could not get off the planes fast enough to relieve their sore backs and necks, the rookies on the other hand to experience the mission. Once entrenched in the work flow, the entire team gained in their unique way an insight into their own personalities, their own beliefs and gained an appreciation for the devastation of neglected spinal pathology and the extent of care needed. By virtue of the previously mentioned generous support we were able to tackle all manners of spine pathology. We did however once again encounter our old limitation of time as well as new

frustrations. These included the lack of intra-operative x-ray facilities, mal-functioning sterilization units and a lack of fresh water for sterilization. In retrospect our “surgical egos” outmatched the available resources. Regardless, the prevalence of treatable spine pathology (neglected trauma, acute trauma, spinal infections, spinal tumors, spinal deformity and degenerative conditions) was excessive, and the need for comprehensive spine care, overwhelming. We stood tall to the task and persevered as is described below. Arrival (January 27th, 2008) After more than 17 hours of nonstop flying, the team arrived in Entebbe. Tired but not worn, the group piled into a van filled to the brim with luggage for an hour long trip to Kampala. With the windows lowered the cool fresh breeze, tinged with the smell of Lake Victoria proved quite rejuvenating. The group arrived at Mosa Court Apartments refreshed, and ready to unload the equipment and plan for the first day. Day 1 (January 28th, 2008) Our first day in Uganda started early, and began with a typical Ugandan breakfast that we would rapidly learn to appreciate. Notable items from the breakfast included passion fruit juice, fresh pineapple and watermelon, as well as Adam's favorite, Ugandan coffee. Once satiated, we packed the gear and headed out. The first stop was to get our U.S dollars exchanged to Ugandan schillings at a local foreign money exchange. After strategic haggling we found a place willing to sell us Ugandan shillings at 1700 per U.S dollar. Next, we headed to Old Mulago hospital, home of Makerere University's Department of Orthopedics, as well as what would soon become our second home. There we were warmly welcomed by the Head of the Orthopedics Department, Dr. Titus Beyeza, as well as Dr. David Denzel, a U.S trained physician who has been involved in mission work in Uganda for the past 15 years! Dr. Denzel talked to us briefly about the future of Orthopedics as well as the importance of Health Volunteers Overseas, and in particular the teaching and training to empower local surgeons to provide orthopaedic care. Dr. Titus Beyeza explained how recent efforts were underway to recruit more general surgeons to become Orthopedists as there was currently a substantial shortage within the country. Dr. Lieberman explained to Dr. Beyeza, Dr. Denzel, and the rest of the team that the Spine Mission had four main goals. The first was to understand the prevailing local conditions, the second to relieve anxiety concerning the longevity and sustainability of a mission, the third to grow and build the spine clinic for further missions and charitable endeavors, and fourth to participate in teaching and training the local health care practioners to provide spine care. After the stop in the office, Dr. Beyeza escorted the team to the newly constructed spine ward to not only view the progress but also to begin seeing patients. To the spine ward was attached a new structure outfitted to serve as an operating room, completely dedicated to spine cases. While it was still under construction, the level of excitement over all the potential possibilities was high.

Table 1 below outlines the patients seen on our initial clinic and ward rounds. (See also Table 4): Table 1: Old Mulago Spine Ward Patients (Seen on 01-28-08)
Name D.M B.N S.N Age 60 22 15 Sex F F F Diagnosis Complex C2 Dislocation T6-T7 Fracture/DislocationComplete Paraplegic Left-Sided Progressive Scoliosis (T7-L3) Thoraco/Lumbar apex at T12 Large Disc herniation C6-C7 Infective Spondylitis L5/S1 Pott’s Disease (Spinal TB) Pott’s Disease (T5-T6) L5/S1 Disc Herniation Lesion at T10-11 L4-L5 Disc Herniation Cervical Kyphosis Neurofibroma extending into C5-C6 Tenderness at L1 Epidural Abscess L4-L5 Discitis, osteomyelitis C5-C6 paraplegic T6-T7 Destructive Lesion C3/C4/C5/C6 Paraplegic L4-L5 Degenerative Stenosis Progressive Deformation (myositis ossificans progressiva) Kyphosis due to Pott’s Disease Spondylolisthesis Treatment Treated with Traction No further surgical treatment Scoliosis Correction with Instrumentation Anterior Decompression and stabilization with instrumentation Anterior L5 corpectomy, decompression, and fusion Anti TB Medication to prevent bone growth Post-Op Patient Anterior Corpectomy and bone graft Decompression, Unilateral Laminotomy T11 Corpectomy, reconstruction, thorocotomy Decompression No further surgical intervention Laminectomy Performed No further surgical intervention Unilateral Laminotomy, Decompression, and Biopsy T4-T5 Posterior Laminotomy No further surgical intervention T6,T7 corpectomy, thoracotomy, decompression, and fusion Anterior decompression

G.A

25

F

C.O N N.S M.K L.O D.B T.K H.W J.K S.B G.T S.L K.B M.B

45 26 29 47 45 36 20 29 21 44 27 40 22 40

F F F F M M M M M M M M M M

M.I

57

M

A.F M.A M.A

9 10 45

F M F

No further surgical intervention recommended Correction of Kyphosis with instrumentation Post-Operative patient

Once the clinic and ward round were completed the team took some time and triaged the patients for surgery. The tentative plan for the first week would be to operate at Mulago hospital Tuesday and Thursday and Mengo hospital Wednesday and Friday. The following week we would operate at Mulago Tuesday and Thursday and Mengo Monday and Wednesday.

After visiting the patients at Old Mulago we traveled to the Uganda Cheshire home in Katalemwa. Uganda Cheshire Home is a privately funded orphanage, shelter, and school for poor and abandoned children. Here we split the team and began examining patients: Table 2: Katalemwa Cheshire Children’s Home Patients (seen on 01-28-08)
Name I.M Age 13 Sex M Diagnosis Kyphosis secondary to Pott’s Disease L5/S1 Spondyloptosis (Congenital Dislocation) Paraplegic Polio Epidural lipomatosis Destructive Sacral Lesion/L5 Lesion Torticollis Post-Operative follow up visit Treatment Anterior T4-T10 Corpectomies Posterior T4-L3 Instrument & Fusion Posterior/Anterior Reconstruction No further surgical treatment No further surgical treatment Posterior Right sided T3-T6 laminotomies and resection Sacral Biopsy No further surgical treatment No further surgical treatment

K.J K.I K.A.I E.E F.B P.N S.L

2 years 3 months 22 11 21 7 16 37

M M M M F F M

As Day 1 came to a close, a variety of emotions unpredictably bounced through each of us. Certainly from a logistical perspective the day was very busy as we saw over 40 patients, established treatment options, and scheduled many for surgery. Most of the patients we examined had succumbed to one of three spine related etiologies: motor vehicle accidents, infections (especially Pott’s Disease/TB of the Spine), and congenital deformities. However, in between all of the ordered chaos, treatment discussion, and documentation, not one of us could ignore or deny the sights and sounds of what unfolded around us. The misfortune of patient A.F. was all but impossible to disregard. Akelu, as she was lovingly called by her grandfather and social worker, was a nine year old girl with a mangled body, who ostensibly had seen far too much pain in her short life. Due to the extensiveness of her deformities and the malignant volume of anomalous bone growth that progressively disfigured her, her case was deemed inoperable. This was crushing to her and her family especially considering the arduous journey from a distant village just to lose all hope (See Figure 1).

Figure 1- Patient A.F, 9 year old female with Myositis Ossificans Progressiva

Even with unfathomably discouraging moments came other encounters that quickly reminded the team of the immense benefit that could improve the lives of others. Patient S.L arrived unannounced at the Katalemwa clinic. He had surgery in 2006 (see Trip report June 2006) to repair injuries sustained in a devastating industrial accident. After being paralyzed and bed ridden for months with a spine fracture, the surgery allowed him to walk into the clinic of his own accord. He appeared in great shape and was so thankful to Drs. Lieberman and Kayanja for restoring much of his function. He had clearly recovered enough function to truly have a new lease on life (See Figure 2).

Figure 2; Patient S.L., 2 year follow up, stable spine, able to walk, Lt to Rt Lieberman, Patient S.L. Kayanja This first day foreshadowed the intensity of highs and lows that the team would experience and really set the tone for the level of impact that could be made by the team’s presence. The team headed back to Mosa Court for what would be the first of many late night dinners. Day 2 (January 29th 2008) Day two was the first day of surgery at Old Mulago. Four surgeries were tentatively scheduled: Patients L.O, M.B, C.O, and T.G. Disappointingly only two surgeries were completed due to lack of water, which was needed to run the autoclave for sterilization of the surgical tools. This lesson reaffirmed the adage of planning for the unexpected. Thus the surgeries of patient M.B and patient T.G were postponed and the surgeries of L.O and C.O were completed. Patient L.O was a forty-five year old man who unfortunately had been suffering for more than eight years with longstanding back pain that seemed to radiate into his gluteal region. He also suffered from a loss of muscle strength rendering him bed ridden. Based on a less than ideal quality CT scan which revealed an ill defined epidural mass lesion we had recommended a decompression operation. At surgery a massive extruded disc fragment was discovered and

evacuated. Post-operatively, patient L.O did exceedingly well and by day three (January 30th, 2008) he had a self reported significant reduction in pain, and very shortly there after regained sensation in his legs. By day 5 (February, 1st, 2008) patient L.O could not be found in the spine ward. Much to our surprise we found him walking about outside, in quite a good mood. His smile conveyed his gratitude (see Figure 3).

Figure 3- Outside Old Mulago Spine Ward. Standing (L to R) Dr. Mark Kayanja, Dr. Titus Beyeza, Dr. Isador Lieberman, Patient L.O., Bharath Surapaneni Patient C.O was a 45 year old woman suffering from progressively debilitating lower back pain over a two week period. She was presumed to have infective osteomyelitis / discitis of her L5/S1 region exacerbated by her immuno-compromised state (HIV+) and TB infection. Her corrective procedure would be an anterior L5 corpectomy, decompression, reconstruction and fusion. Post-operatively she reported less back pain and only slight abdominal pain, probably due in part to her anterior abdominal incision. By day 10 (February 6th, 2008), she reported increased sensation and a feeling of heaviness in her legs. She was started on anti-TB medication on confirmation of her culture results (See Figure 4).

Figure 4- Smiles All Around. (L to R) Dr. Selvon St.Clair, Patient C.O, Dr. Isador Lieberman

Later that day the surgical supplies arrived. They had previously been held up in Entebbe and were now waiting to be moved into the OR. Once they saw the piles upon piles of linens and tools that just flooded the tiny hall of the Old Mulago operating room, Dr. Nyati and the operating room staff were all particularly pleased to see the new supplies. (See Figure 5)

Figure 5-Arrival of Surgical Supplies. (L) Dr. Titus Beyeza oversees supplies (R) Supplies fill narrow hall of Mulago OR. Day 3 (January 30th, 2008) Today would be the first day of surgery at Mengo hospital operating theatre which was without a doubt more organized and newer than the operating room at Old Mulago. After a brief stop at Old Mulago to check on the post-operative patients the team made its way to Mengo. There, Dr. Lieberman reassured the team that though we only completed two out of four surgeries yesterday at Old Mulago, treating those two patients with the limited resources at hand was still beneficial and far more cost effective than surgery on a single patient in the U.S. The surgeries scheduled for Mengo were those of patients E.A and A.N. Patient E.A was an adorable three year old girl with a congenital kyphosis. Her corrective procedures involved an anterior release of (T10-11, T11-12) as well as a posterior release and fusion of (T9-L1). Her surgeries took place in two parts (January 30th and February 6th 2008). Her post-operative course was unremarkable. She had steadily improved (See Figure 6) and was discharged after we had left Uganda.

Figure 6- Patient E.A, first seen at Katalemwa Cheshire Children’s Home, Post-Op (1/30/08)

Patient A.N was a seventeen year old female with progressive idiopathic scoliosis. Her corrective procedure was to be done in two parts. First would be a right anterior release (T4T11) followed later by a posterior correction, fusion and instrumentation (See Figure 7). Her right sided anterior release was performed on January 30th 2008, without any adverse events. On February 1st, 2008 at around 7:00 PM as the team was loading up the van with supplies, the anesthetist David Snell discovered A.N to be in significant respiratory distress. Her breathing was labored and clinically it appeared that her chest had filled with fluid due to mal-function of the chest tube. We used intercostal blocks to relieve her pain and further drained her chest in the hopes of her being able to cough up any remaining mucus plugs in her airways. She did not improve with these maneuvers and progressively deteriorated. We then re-intubated her, and it became clear that we were reaching the limited capacity for treatment at Mengo and that A.N would need to be mechanically ventilated. Unfortunately we were unable to initially find a place with a ventilator to accept her. As such we elected to manually ventilate her through the first night. The following day we were able to negotiate a bed and ambulance transfer to the International Hospital of Kampala (a private hospital with ventilator support). Dr. St.Clair, along with the anesthetic team of Dr. Sara Hodges, David Snell, and Maria Aguti, accompanied patient A.N to IHK (International Hospital Kampala) ICU at 11:00 AM on Saturday February 2nd, 2008 (Day 6). Once there, an x-ray confirmed complete collapse of her left lung. The team attempted with only little success to evacuate any bronchial obstruction and mucus plugs, using a reclaimed bronchoscope. We decided to continue as best as possible with chest physical therapy, ventilation and anti-biotics to support A.N. Due to minimal improvement, a tracheostomy was recommended and performed on Sunday February 3rd, 2008. This proved to be the turning point for her as now she began to improve. By February 7th 2008, it was reported by physiotherapy staff that A.N was cooperating with breathing exercises. As of February 28th, 2008 it was reported that patient A.N was progressing well and was up and walking. The experience with A.N. reminded the team just how fragile the situation could be, just how important proper imaging and equipment are, and the resilience of the human spirit. We were unable to complete the posterior correction and fusion.

Figure 7-(L) Patient A.N, first seen at Katalemwa Children’s Home (R) Patient A.N’s collapsed Left Lung

Day 4 (January 31st 2008) This would be the second day of surgery at Old Mulago and meant to be the most ambitious. We had scheduled six surgeries. Much to our chagrin, as we started the first two cases in separate operating rooms, we were advised that the autoclave once again ran out of water. We did still manage to complete four surgeries, those of patients S.N, S.L, M.I, and T.G. Patient S.N was a fifteen year old female with left sided progressive scoliosis (thoracic kyphoscoliosis) whose corrective procedure would take place in two parts (See Figure 8). The first procedure involved anterior multi-level releases and took place on January 31st, while the posterior correction, fusion instrumentation procedures were scheduled for February 5th 2008 (Day 9). After patient S.N’s first procedure, she entered recovery at the Old Mulago spine ward where she was placed in 30⁰ gravity traction and monitored closely. By February 5th, it was clear that S.N was strong enough and eager to begin her second procedure. After her second procedure, patient S.N was transferred to New Mulago ICU where she remained stable overnight. Quite memorably, when visiting patient S.N at New Mulago the day after her 2nd surgery the only thing she requested of us was an Orange Fanta!

Figure 8- Patient S.N, (L to R) Intake, X-ray showing L sided scoliosis, and 30⁰ gravity traction Patient S.L was a forty-six year old male suffering from lower back pain and leg weakness. On the basis of his history, clinical findings and investigations he was presumed to have L4-L5 discitis and osteomyelitis with an epidural abscess. This required debridement through a posterior decompression. After surgery, S.L quickly regained sensation in his lower extremities and reported increasingly less pain in the days following surgery. Patient M.I was a fifty seven year old retired general practitioner suffering from lower back pain, loss of muscle strength in his lower extremities, and problems with finely coordinated tasks all sustained from a motor vehicle accident in 1996. After the accident, patient M.I was unable to walk but slowly over one year gained that ability with a cane for added support. Investigations revealed multiple level cervical degeneration with prolapsed discs. The culprit level was estimated to be C3-C4, although the other levels were degenerate and stenotic as well. It was also determined that patient M.I may be suffering from degenerative spinal stenosis at the lumbar L4-L5 level, perhaps intensifying his symptoms. He was scheduled for an anterior multi-level decompression and fusion of the cervical spondylosis. Due to lack of appropriate imaging at the time of surgery, it became difficult to precisely identify the correct cervical levels and thus a second revision surgery was scheduled for February 5th, once adequate post-op

imaging was reviewed (See Figure 9). After his second procedure, patient M.I reported some initial improvement of his pain, although he still felt weakness in his arms and legs. On final review we recommended he pursue physical therapy to improve his strength.

Figure 9- Patient M.I, X-rays taken (February 1st, 2008) after 1st procedure. Patient T.G was a twenty seven year old male paralyzed from the waist down, with loss of bowel and bladder function. He was presumed to have an epidural abscess at the T4-T5 level, requiring a unilateral laminotomy, decompression, and biopsy (See Figure 10). After the procedure, patient T.G reported new sensations in his right leg, specifically burning and tingling. Although T.G was still unable to wiggle his toes or move his lower extremities, his report of paraesthesia was encouraging. His subsequent biopsy report was negative.

Figure 10- Patient T.G, CT Scan and x-ray indicating possible epidural abscess. In addition to making sure we were always properly fed and caffeinated, the dedicated nursing and support staff of both Mulago and Mengo hospital were tireless in their work ethic, deep in their compassion, and always light hearted. Rather than dismiss the team as a group of outsiders, they exceeded all expectations in efforts to not only get to know us, but also to make us feel as one of their own. Every morning, Sister Emmy’s warm greeting really provided the team an extra kick start for the day (See Figure 11).

Figure 11- (L to R) Old Mulago Support Staff, Delicious Ugandan Lunch, and Sister Emmy

Day 5 (February 1st, 2008) Day five marked a return to the Mengo Hospital for surgeries on patients H.K and A.Y. Patient H.K was a five year old girl who suffered from a congenital dislocation (spondyloptosis) of L5/S1. This required a whole day of surgery including a posterior release of levels L4/L5/S1, anterior release of L5/S1, and a posterior fusion of levels L3-S1. After surgery H.K entered recovery at C.O.R.U (Children’s Orthopedic Rehabilitation Unit) and by the next day she was recovering well with stable vital signs. She remained neurologically intact with movement in her legs, and her mother reported that she was experiencing mild pain in her back. By February 7th, H.K appeared very well, was smiling, and playing intently with her doll and stuffed animals (See Figure 12). Patient A.Y was a thirty-five year old cachectic male who was suffering from disabling, chronic lower back pain and reduced muscle strength and sensation in his lower limbs. His investigations revealed an L1 osteolytic (bone destroying) fracture presumably due to osteomyelitis (bone infection). This was addressed by a posterior L1 exposure, decompression, biopsy and reconstruction. During surgery we were suspicious of the presumed diagnosis, now favoring some sort of tumor. The day after surgery, patient A.Y reported feeling much better and that he had less pain. In addition, he began to regain sensation in his left thigh to the knee. Before surgery he had no sensation in his left leg. By February 7th, A.Y appeared tired but in no apparent distress. The biopsy result from the sample taken at the time of surgery confirmed our suspicion of cancer with a diagnosis of adenocarcinoma, possibly of lung origin. He was eventually transferred to Mulago Hospital for an oncology consultation.

Figure 12- (L to R) Patient H.K Post-Op, Pre-Op X-ray, Post-op X-ray Day 8 (February 4th, 2008) Three pediatric operations were scheduled at Mengo hospital for day eight. By the time the surgeries of patients N.L and F.B were completed, it was mid-afternoon and thus the third scheduled surgery, the surgery of patient K.J, would need to be postponed until the next mission. Patient N.L was a thirteen year old paraplegic girl whose spinal deformity formed a sharp bump in her lumbar region which prevented her from sitting comfortably (See Figure 13). She was diagnosed with Pott’s disease (Tuberculosis of the Spine) at the L2/L3 level, requiring an anterior release/reconstruction as well as a posterior instrumentation procedure. N.L’s deformity was remarkable for the fact that it left her spinal cord vulnerable to injury due to the complete destruction of the posterior vertebral elements. This deformed configuration of her spinal cord clearly played a major role in the development of her paraplegia. After her surgery, N.L’s back was visibly much straighter and what remained of her massive bump was now flat.

She still lacked the ability to move her toes or legs but appeared generally well with no complaints of pain. Patient F.B was a seven year old girl with a destructive sacral lesion that appeared to be pathologic, for which we recommended a right sided open posterior alar biopsy. Based on her available imaging, it appeared that F.B might have an eosinophilic granuloma (benign typically childhood tumor, See Figure 14). However, the differential pathologic diagnoses also included osteosarcoma, chondroma, or Ewing’s sarcoma. After surgery, F.B’s incision healed quickly and she was started on antibiotics as the tissue taken for biopsy was more consistent with infection than tumor. The pathology and microbiology results at 48 hours were inconclusive.

Figure 13- (L to R) Patient N.L positioned for surgery (Top-Anterior), Pre-Op & Post-Op X-Ray

Figure 14-Patient F.B (Pathologic Sacral Lesion) CT Scans Day 9 (February 5, 2008) Today took the team back to Old Mulago for the revision surgery of patient M.I and the second part of patient S.N’s scoliosis correction. Two other patients were also originally scheduled for this day including patients F.N and R.K. Both were ultimately postponed due to uncontrolled hypertension and diabetes. After S.N’s surgery, she was transported to New Mulago ICU where she remained stable overnight. By February 6th, she was neurologically intact, with stable vitals and we had removed her chest tube. After patient M.I’s revision surgery he reported feeling much better but still had weakness in his legs and less flexibility in his left arm.

In addition to the flavorful breakfast jam each morning the team often tasted a “jam” of a different kind. The traffic jams in Kampala were epic. At times, even impassable, and it certainly made operating a tight schedule very difficult. The road conditions were likewise troublesome (See Figure 15). We did have the luxury of an experienced driver. Alex had become quite resourceful at getting us through the melee at breakneck speeds so that we could manage the daily responsibilities at multiple hospitals. It also helped that the team divided up to visit each hospital early in the mornings allowing time to return to join the other half in surgery before rush hour hit.

Figure 15-(L to R) Kampala Traffic, Roads with canyon-like potholes

Day 10 (February 6, 2008) Three surgeries were scheduled for Day 10 although only two were completed. Patient I.M unfortunately contracted malaria only a few days before his scheduled operation and thus would require a round of treatment with chloroquine prior to an operation. The other scheduled patients for surgery, E.E. and E.A. were completed. The procedure for E.A was the second part of her scoliosis correction. The first part of the correction took place on January 30th (Day 3), and involved the anterior release of levels (T10-11, T11-12). This day’s procedure would be the posterior release and fusion of (T9-T11). She did well post surgery with no adverse issues affecting her recovery. Patient E.E. was a twenty year old male who quite suddenly lost the ability to walk about three years prior. He had no sensation in his lower limbs but had maintained bowel and bladder functioning. From imaging it was presumed that he may have an epidural lipomatosis (See Figure 16). His procedure would be a posterior right sided (T3-T6) laminotomy and resection. One day after his surgery, E.E. still had tremors and clonus. Two days after surgery, quite remarkably, he could move his toes as well as his knees and appeared to have no tremors or clonus (involuntary muscle contraction) which was very promising. Nevertheless, there was still no biopsy report available at the time.

Figure 16- Patient E.E (L to R) CT myelogram indicates extra-dural tissue with features common to extra-dural neoplasm, lymphoma, metastatic disease, or lipomatosis. Day 11 (February 7, 2008) Our final day of scheduled surgery would take place at Old Mulago, right where we started. Four surgeries were again scheduled; patients M.A, F.N, A.G, and R.M. Due to multiple reasons including lack of anaesthetic coverage and a very late start, only the surgeries of A.G and R.M were completed. Patient R.M was a thirty five year old female who was diagnosed with a unilateral facet dislocation at the C4/C5 level. This was treated with a posterior reduction and stabilization procedure. Post operatively she reported improvement in her neck pain. The final patient A.G was a twenty-five year old female suffering from complete C5 level paraplegia. She was in a car accident on January 17th, 2008. Her investigations revealed a large disc herniation at the C6-C7 level. We proceeded with an anterior discectomy and fusion. Once again we did not have any intra-operative x-ray capability to help verify the level. Despite an extensive exposure the wrong level was decompressed. This was not confirmed until the morning of our departure as we could still not get x-rays done immediately after surgery. The entire team was devastated as we all felt this was one patient we could have possibly helped. Day 12 (February 8, 2008) Our last day in Uganda started off at Old Mulago where Dr. Selvon St. Clair and Dr. Mark Kayanja presented didactic lectures to the department of Orthopedics. Later, the team went to Mengo and IHK to check on all of the patients. Dr. St. Clair presented a lecture entitled “Surgical Exposures of the Thoracic and Lumbar Spine”. He covered anterior, posterolateral, and posterior approaches including the transthoracic, thoraco-abdominal, costostransversectomy, flank retroperitoneal approach, and trans-peritoneal approach. The key point of the lecture was that the approach chosen should match the patient’s pathology to minimize healing time and to avoid complications. Dr. Mark Kayanja presented a lecture entitled “Spine Biomechanics” that covered many important central concepts in spine biomechanics such as “load to failure” which occurs when a loads exceed the load bearing capability of the spine. He also explained that the spine is exposed to forces and displacements and that in response, the spine answers by allowing or limiting movement. Transitional areas of the spine, the cervico-thoracic junction and the thoraco-lumbar junction, are vulnerable and bear relatively greater biomechanical stress. This

increased biomechanical stress often leads to injury in these areas. Also, within the structure of vertebral bone there are horizontal and vertical ties and both elements are critical to the force bearing nature of vertebra. Thus when there are conditions that compromise the regular vertical/horizontal matrix, such as osteoporosis or tumor infiltration, injury can occur. During the lecture, Dr. Titus Beyeza asked whether the lifestyles of Ugandan women, especially the repeated activities such as farming, dancing, and cooking could predispose them to stress injuries of the facet joints and thus to spondylolisthesis (slipped vertebral body). Dr. Lieberman responded with an example of how lifestyle can definitely affect the demographics as well as injury profile of a population. He went on to describe his observations while traveling through Nepal with the Sherpas. There he noticed a paucity of men over the age of fifty-five but plenty of women of this age or older. He didn’t understand why until he visited the local hospital. Since many of the Sherpas work as porters, their livelihood involves carrying heavy parcels on their backs supported by a strap around their foreheads. Because of this repeated stress on cervical spine they are predisposed to cervical spondylosis (degenerative arthritis) and myelopathy (compression of the spinal cord leading to gait disturbance and imbalance while walking). Due to the myelopathy they fall while working either breaking their necks or breaking their femurs (thigh bone) which are both life threatening injuries from which many do not recover. After the lectures, exchanges of thanks were made by both Dr. Titus Beyeza and Dr. Lieberman (See Figure 17)

Figure 17- (L to R) Spine team and Mulago Dept. of Orthopedics group pictures

Epilogue; Bharath Surapaneni When reading the daily newspaper while stuck in a “jam”, I came across a quote that our driver Alex had explained to me. After his explanation I thought about it quite a bit and tried to reflect on what it really means. In Uganda, the saying "Omulya mamba aba omu navumaganya ekika" means that one man’s sin reflects not only himself but also on all of his people. I came to realize though, that if this is true then the converse must also be true, which is, that one man’s goodwill must also reflect not only on himself but also on all of his people. Therefore in terms of the spine mission, the work of the spine team was not an isolated event to be lost or forgotten, but really a reflection on all of our intrinsic capacity, our capacity as health care workers and members of society to help heal and comfort, to teach and cultivate, and to create and inspire. And so, by planting the seeds of goodwill today, we will certainly ensure the continued forest of goodwill and reciprocity tomorrow. Epilogue; Selvon St. Clair This was my first trip with the Uganda Spine Surgical Mission and undoubtedly will not be the last. Even though fore warned by both Drs. Lieberman and Kayanja, I was still astounded by the relentless varied spine pathology and the lack of basic medical resources to adequately treat patients in Uganda. Throughout the fortnight, I was constantly reminded of my favorite Einstein quote : "only a life lived for others is worth living". For the first time in my career I fully understood what it meant to live for others and contribute selflessly towards the human condition. I quickly realized how much good can be done with so little. Although we were constantly frustrated by the lack of resources and overall logistical difficulties, our mere presence was sincerely appreciated by all. I was especially touched when one of the orthopaedic surgeons walked up to me and said, "thanks for helping Ugandans". However, at the end of the trip, I was very saddened by our failures, which left an indelible impression on me and a burning desire to continue to partake in this and other global surgical spine missions. Epilogue; Adam Rodatt After participating in the Uganda mission 08’ trip, the reward of helping others is beyond description. One can never be completely prepared to tackle the medically challenged in a different part of the world, away from our highly technical society. Simple things, such as paper towels, trash receptacles, electrical extension cords, and water were not readily available and we had to re-educate ourselves to be without. The positive energy that radiated from the team was just as powerful as our surgical skills with the families, patients, and hospital staff. We adapted quickly and adjusted as problem solvers to the simplicity. This mission was only the beginning, more will follow, as education is addicting to all that is touched. As a nursing professional and colleague, it truly was an honor to assist the surgeons involved and a privilege to be part of this mission. Epilogue; Mark Kayanja Returning to Uganda for the 3rd Spine Mission was a trip down memory lane. The problems that we encountered were reminiscent of what had collectively created an urge in me to try to advocate for change. Problems like lack of intra-operative X-rays, water shortages infiltrating surgical lists, neglected spinal pathology served as fuel to my drive and commitment to the Uganda Spine Mission. With all the great support and commitment from the people involved in the mission I believe there has been an impact on the lives of several Ugandans. I look forward to the mission growing and blossoming as we head into the future. I say "Gakyali mabaga," the motto from my High school in Uganda which means there is plenty of work ahead!

Epilogue; Isador Lieberman After two very successful missions to Uganda I returned with a strong team (see Figure 18), plenty of equipment, far less anxiety and an invincible outlook. By the end of the mission it was clear that my surgical ego outmatched the environment and resources. Having seen more patients this trip than in the past, having triaged many more severe cases, I directed the team to take on more than we realistically could have. We left behind many disappointed patients and families for whom which, we simply ran out of time. The lack of ICU facilities and intra-operative x-rays frustrated me beyond any frustration I had ever experienced as a surgeon. In retrospect I did inflict on three patients more than I can now justify, with limited if any benefit. These lessons are tattooed on my mind. I can only hope this will in some way help others.

Figure 18 – Dr St Clair, Dr Kayanja and Mr Surapaneni

http://www.firstgiving.com/UgandaSpineSurgeryMission2008-2009

Table 3; 2008 Surgical Cases
Date 1/29/2008 1/29/2008 Name L.O C.O Age 45 49 Sex M F Diagnosis L4/5, L5/S1 Disc Herniation Infective Spondylitis L5/S1 Procedure Decompression L5 Corpectomy Decompression Fusion Anterior Release T10-T11, T11-T12 and corpectomy of T10 Right anterior release T4-T11 Anterior Thoracotomy, Release of T10/T11, T11/T12, T12/L1 Posterior Decompression L45 C/4/5/6 Anterior Release Unilateral Laminotomy Decompression, Biopsy T4/T5 Anterior Release L1-L4, Posterior Release L4/L5/S1 and fusion L3-S1 Posterior Release L1 Anterior Release and Reconstruction and Posterior Instrumentation Alar Open Biopsy C3/C4 Anterior Decompression and Fusion Scoliosis Correction with Instrumentation Posterior Rt Sided (T3-T6) HemiLaminotomies and Resection Posterior release and fusion Anterior Decompression and Stabilization C6/C7 Corpectomy Reduction and Stabilization C4/C5 Unilateral Reduction and Fusion

1/30/2008 1/30/2008 1/31/2008 1/31/2008 1/31/2008 1/31/2008

E.A A.N S.N S.L M.I T.G

3 18 15 46 57 27

F F F M M M

Scoliosis Scoliosis Left Sided Progressive Scoliosis L4-L5 Discitis L4-L5 Degenerative Stenosis + C4/C5, C5/C6 Epidural Abscess

2/1/2008 2/1/2008 2/4/2008 2/4/2008 2/5/2008 2/5/2008 2/6/2008 2/6/2008 2/7/2008

H.K A.Y N.L F.B M.I S.N E.E E.A A.G

5 35 13 7 57 15 20 3 25

F M F F M F M F F

Congenital Dislocation L5/S1 L1 Fracture/Osteomyelitis Pott's Disease (TB of the Spine) Destructive Sacral Lesion Prolapsed Discs C3/C4, C4/C5 Thoracic Kyphoscoliosis T7L3 Epidural Lipomatosis Scoliosis C6/C7 Disc Herniation

2/7/2008

R.M

35

F

Unifacet Dislocation C4/C5

Table 4- 2008 Patient List (CCHK-Cheshire Children’s Home Katalemwa) Age Cat. Name Date Location Symptoms (Sex) neck pain Old after car I.P D.M 60(M) 1/28/2008 accident Mulago I.P I.P I.P I.P I.P I.P I.P I.P I.P B.N S.N A.G C.O N N.S K.M O.L D.B 22(F) 15(F) 25(F) 45(F) 26(F) 29(F) 47(F) 45(M) 36(M) 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 1/28/2008 Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Old Mulago Complete Paraplegic Progressive Curvature Complete Paraplegic Lower Back Pain (HIV+) Lower Back Pain Lower Back Pain Lower Back Pain Loss of strength in lower limbs Progressive Pain Low Back Pain, Lower Limb Weakness HyperReflexive on Left Side Decreased Strength in Lower limbs Low Back Pain, Lower Limb Weakness Loss of bowel and bladder function Low Back Pain, Lower Limb Weakness Loss of power in lower limbs, Pressure Sores Paraplegic Dragging legs, tremors, loss of sensation in fingertips

Diagnosis Complex C2 Dislocation T6-T7 Fracture/Disloc ation Left-sided Progressive Scoliosis Large Disc Herniation C6C7 Infective Spondylitis L5/S1 Pott's Disease (TB of the Spine) Pott's Disease (TB of the Spine)

Treatment Treated with traction No further Treatment Scoliosis Correction Anterior Decompression and Stabilization L5 Corpectomy, Decompression, Fusion Anti-TB Medication to prevent bone growth Post-Operative Anterior Corpectomy and bone graft Decompression T11 Corpectomy, Thorocotomy

Disc Herniation L4/5, L5/S1 Lesion @ T10T11 L4-L5 Disc Herniation Cervical Kyphosis neurofibroma extending into C5-C6 Tenderness at L1 Pott's Disease (TB of the Spine) L4-L5 Osteomyelitis Previous C5-C6 Fracture T6-T7 Fracture/Disloc ation Prolapsed Discs (C3,C4,C5,C6) L4-L5 Stenosis (Degenerative) Myositis Ossificans Progressiva, Anomalous Bone

I.P I.P I.P

K.T H.W K.J

20(M) 29(M) 21(M)

1/28/2008 1/28/2008 1/28/2008

Decompression No further Treatment Received Laminectomy Post-Op

I.P I.P

B.S T.G

44(M) 27(M)

1/28/2008 1/28/2008

No further Treatment Unilateral Laminotomy Decompression, Biopsy T4-T5 Posterior Decompression Laminotomy

I.P

L.S

40(M)

1/28/2008

I.P I.P

K.B B.M

22(M) 60(M)

1/28/2008 1/28/2008

No further Treatment T6-T7 Corpectomy, Biopsy Required

O.P

M.I

57(M)

1/28/2008

Old Mulago

Anterior Decompression and Fusion (C3/C4)

O.P

A.F

9(F)

1/28/2008

Old Mulago

Trouble Breathing

Unable to Provide Treatment

O.P

M.A

10(M)

1/28/2008

Old Mulago Old Mulago Old Mulago

O.P O.P

M.A R.K

45(F) 48(F)

1/28/2008 1/28/2008

Back Swelling, Pain in the legs, cannot stand PostOperative complaints of pain Paraparesis Lower back pain, reduced strength and sensation in lower limbs

Pott's Disease (TB of the Spine) L5-S1 Spondylolisthes is C5/C6 Spinal Cord Compression

Stabilize Spine (Anterior/Posterior Approach)

CT myelogram for review C5/C6 Corpectomy and Fusion

O.P O.P

M.N F.N

60(M) 68(M)

1/28/2008 1/28/2008

Old Mulago Old Mulago Old Mulago CCHK

Spinal Stenosis L4/L5, L5/S1 Cervical Spondylosis Unifacet Dislocation

O.P O.P

M.R N.P

35(F) 16(F)

1/28/2008 1/28/2008

Right sided Laminotomy B/L Decompression Anterior Decompression and Fusion (C3/C4) and (C4/C5) Reduction and Stabilization C4/C5 Unilateral Reduction and Fusion Plain x-ray requested prior to further work up.

O.P O.P

S.L E.A

37(M) 3(F)

1/28/208 1/28/2008

CCHK CCHK

Increasing pain in her neck PostOperative complaints of pain

Torticollis

Kyphoscoliosis

O.P O.P

I.M K.J

13 2(M)

1/28/2008 1/28/2008

CCHK CCHK

Trouble Breathing Paraplegic has no sensation/moti on in lower limbs. Lower limb discrepancy, scoliosis No sensation in lower limbs, weakness in legs. Left curve scoliosis

Pott's Disease, Kyphosis Spondyloptosis L5/S1

No further Treatment Anterior Release (T10-11, T11-12) Posterior Release + Fusion (T9-L1) Anterior T4-T10 Corpectomies/reconstructi on, Posterior T4-L3 instrumentation and Fusion Posterior/Anterior Reconstruction Unlikely to regain sensation with surgery since time since accident has been 4 years.

O.P

M.I

22(M)

1/28/2008

CCHK

O.P

K.A.I

11(M)

1/28/2008

CCHK

Polio (Characteristic gait and scoliosis) Neurological Scoliosis (Epidural Lipoma) Congenital dislocation L5/S1 Spondyloptosis L1 Fracture/Osteo myelitis/Adenoc arcinoma Pott's Disease (TB of the Spine) Destructive Sacral Lesion Posterior Right Sided Laminotomies T3-T6 and resection Posterior release L4/L5/S1 → anterior release L5/S1 → posterior L3-S1 fusion

O.P

E.E

21(M)

1/28/2008

CCHK

O.P

H.K

5(F)

1/28/2008

CCHK Lower back pain, reduced strength and sensation in lower limbs Paraplegic, difficulty sitting due to deformity Sacral Deformity

I.P

A.Y

35(M)

1/29/2008

Mengo Hospital

O.P O.P

N.L F.B

13(F) 7(F)

1/28/2008 1/28/2008

CCHK CCHK

Posterior Release L1, fusion Anterior Release/Reconstruction and posterior Instrumentation Alar Open Biopsy

O.P O.P

J.B A.N

14(F) 17(F)

1/29/2008 1/29/2008

Mengo Hospital Mengo Hospital Mengo Hospital

Kyphosis Progressive Curvature

T4-L2 Kyphosis Prog. Idiopathic Scoliosis Pott's Disease (TB of the Spine) T8-T9

O.P

N.P

12(F)

1/30/2008

Kyphosis

Posterior Correction with Instrumentation Right Anterior Release (T4-T11) Anterior Release/Reconstruction and posterior Instrumentation