3rdMissionReportSpineCare@CUREUgandaMonday1stuntilWednesday3rdFebruary20162ndMbararaNeurosurgicalCampBelgianteam:Ricky-Hans-Katrien-DirkUgandanteam:David–Alex–Tom–AndrewSunday31January2016ArrivalinMbararaandquickstop.Katrientooktoleadtodeliverallthemedicalsuppliesandinstrumentswewereabletocarrywithus.IntheeveningwemetagainwiththenursesTomandAndrewanddr.DavidKityafordinneranddiscussions.Weregrettedthesmallerteamas2membersdroppedoutonly3-4daysbeforethestartofthecamp,notallowingusenoughtimetofindreplacements.AtMRRHmostoftheneurosurgicalproceduresremaintrauma(mostlyduetomotorcycleaccidents).Adedicatedneurosurgicaltheatreeverydaywouldallowmoreelectivecases.Thecurrentdepartmentofneurosurgeryhoweveratthismomentonlyconsistsofdr.Kityaandthe2nursesTomandAndrew,makingthemcontinuouslyoncall.Westronglysupportthetransferofdr.AlexfromMulagoHospital,Kampala,toMRRH.AnotherimportantdiscussionaretheneurosurgicalcampsofDukeUniversity,dr.HäglundandtheSpinalSurgerycampsoftheTexasBackInstitute,dr.Liebermann.Woulditbepossibletojoinforcesofallthreeteamstoincreasequalityandmaintaincontinuityincare???Hans,independentsalesmanagerforNuvasive,mentionsthattheDuketeamalsocooperateswithNuvasive.ThefirstcontactswiththeNuvasiveSpineFoundationhavealreadybeenmade.Mr.PitchoufromNuvasiveheadquartersjoinedtheformerteam.BryanCornwall,directoroftheSpineFoundationhasbeenupdatedbyHansacoupleofweeksagoinSanDiego.Amicrodiscectomyset,worth20000$,hasbeenpromisedtotheMbararaNeurosurgicaldepartment.Ashortoverviewofthesurgicalprogramwasgiven.Oneoftheproblemsweencounteredisthelackofanaesthesiologicalmedication.Ifpatientscannotprovideforit,thesurgeryhastobecancelled/postponed.

Monday1february2016Thecampstartedattheemergencydepartmentwherewesawanddiscussedsometraumaandpostoperativecases.Wecontinuetotheprivatewardandsurgicalwingtoseethesurgicalcasesforthecamp.Oncethepatientswereseentheagendaforthenextthreedayswasmade.Severaloutpatientswerepresentforajoinedoutpatientclinic.Surgicalandnon-surgicaladvicewasgiven.Onepatientwithaherniateddiscwasdecidedtobeasurgicalcase,butpreferredtogotoIndiaorSouthAfrica.Onourwaytotheatrewemetthehospitaldirectorwithwhomwehadashortmeeting.Wetransferredtotheatretostartupthefirstsurgeries.Unfortunatelytherewasnoanaesthesiologistavailablesowehadtopostponethesurgicalcamptothenextday.Anelderlyladywithalargeolfactorymeningiomaortuberculumsellaemeningiomacouldnotbeoperatedduetolackoftime.TheBelgianteamdecidedtovisitOURS,acommunitybasedrehabilitationcenterforspinabifidaandhydrocephaluschildrentohandoverthepackage

providedbyIFSBH.Atpresenttherewerenoadmittedchildren,onlyoutpatientevaluationsandtreatments.Wegotaguidedtouralongthefacilities.Pediatriccathetersareneededandwepromisedtotryandgathersomeinthecomingyearforthenextmission.NextwetransferredtotheRuharomissionandtheeyeclinic,wherewemetdr.KeithWaddell,

BritishOphtalmologist,residinginUgandafor52years.Wevisitedtheclinicanddiscussedsomecases.Everyonewasimpressedbythetremendousworkhehasbeendoing.Theclinictreatedlastyearover80retinoblastomas,averyraretumouroftheeyeinthewesternworld.HeprovesthatalsoinUganda,withlimitedresourcescertainmalignanttumourcansuccessfullybetreated.Inearlystageanddiagnosiseyesavingtherapyispossible,inlaterstageremovaloftheeye,togetherwithbleomycinisnecessary.

Everyoneagreesontheabsolutenecessitytoprovideaprostheticeyetoavoidoutcastingthepatientsfromthecommunity.CurrentlyhehasenoughfundingfromanEnglishfamilytocoverthecosttoruntheclinic.Additionalfundingwouldbebeneficialforcontinuationoftheproject,asgovernmentalsupportseemsratherunlikely.

Tuesday2February2016At7.30wecanstartupsurgeriesin2theatres.Wedecidedthatdr.Alexwouldstartupacraniotomyforaleftfrontallesion.Totalremovalofthelesionwasplanned,butasweopenedthedurathebraintissueseemedtoberathernormalandwedecidedtodoalargebiopsywithoutriskingmotordeficit.Paralleltothiscasewedida2-levellumbardecompressioninalumbarlateralrecessstenosis.SisterLeocardia,thepatient,underwentACDFbytheDuketeamacoupleofmonthsearlier.CTscanshowedagoodreconstructionanddecompressionattheC5C6level.Nextcaseintheatre4wasabilateralchronicsubduralhematoma,surgicallytreatedbyabilateralburrhole.Oldbloodevacuatedunderpressureandbeingayoungpatientthebrainexpandednicelysonocavitywasleft.Dr.Rickyheldaclinicalpresentationofthecasestothemedicalstudentspresentintheavailabletime.

Hesuggestedthecreationofasubcutaneouspouchforfurtherdrainageofthesubduralspacetoavoidexternaldrainagefor48/72hours.ThenextcasewasamultilevelcervicalspinalstenosisinwhichweperformedaclassiccervicallaminectomyC2C7.Luckilythepatientstillhadalordoticcervicalspine,sononecessityforlaminoplastyorlateralmassreconstruction.

Thelastprocedureforthedaywasayoungfemalepatientwitharightcerebellarhemangioblastoma.OntheCT-scanasecondlesionatthecraniocervicaljunctionontheleftsidewasshown.Thelesionwascontrastenhancedandnon-cysticontheposteriorside,soweallthoughtitbeingameningioma.

Afterdr.AlexopeningtheposteriorfossaandremovingC1thedurawasopenedanddr.Rickytookoverexploringtheposteriorarea.Therewasnoclearmeningioma,onlyaberrantbloodvesselsoverlyingthespinalcord/brainstem.

Duringthe(careful)explorationtherewasbleedingnecessitatingtheremovalofthelesion.Clinicallyitseemedtobeanon-cystichemangioblastoma.Oncefinishedweconcentratedonthecysticlesion.Asmallcorticotomywasmadebutthelesionwasnotretrieved.Weswitchedtoapuncturewithacushingneedlehelpingintheapproachtothecystabitmorecranialandlateral.Oncethecystwasopened,theorangelookinglesion

couldeasilyberemoved.Hemostasiswaseasyforthecysticlesionbutthebrainstemlesioncausedsomemoreproblemsofbleeding.EventuallyhemostasiswaspossiblewithFlosealandloweredbloodpressure.Thecalmcontinuationandpatiencetofinallyreachhemostasisofdr.Rickyseemedtohaveimpresseddr.Alexandtherestofthepeoplepresent.Wednesday3February2016Thefinaldayoftheneurosurgicalcampstartedattheemergencydepartment.Severalnewcaseswereadmitted.Onetraumacasethatwaspresentedshouldbediscussed,asitwouldbethelastcasetreatedduringthecamp.Ayoungmalewaspresumeddeadaftertraumaand“thrownaway”.HewasstillalivebutquadriplegicandbroughttoMRRH.LateralX-rayofthecervicalspineshowedabilateralfacetjointdislocation.Asthefirstpatientswerealreadyintheatreandanaesthesiastartedweplannedhimforanattempttoclosedreductionundersedationandfullmusclerelaxation.Unfortunatelyallattemptsforclosedreductionfailedandwedecidedtotransferpatienttothewardandstarttractionforsometime.Non-instrumentedsurgery(notavailable)wasdecidednottobebeneficialforthepatient.Thefirstcasewasa2-levelACDFwithiliaccrestbonegraftandcervicalplate.Agooddecompressionandreconstructionwasaccomplished.HansexplainedhowtomanipulatetheC-armtoDavidandAndrew.Parallelintheatre4Dr.AlexandDr.Davidstartedaseverecaseofright-sidedexophthalmia.CTshowsanintra-orbitallesionprotrudingtheeyewithanintracranialextension.Theyremovedthelesiontogetherwiththeophtalmologist.Around2pmtheneurosurgicalcampcametoanend.Wepromisedtocomebackin2017andstayafullweek.Weshouldbringananaesthesiologistandasecondneurosurgeonorspinesurgeon.Ricky

Specialthankstofollowingpartnersandsponsors;supportingourmission.IFSBH http://www.ifglobal.org/en/CHILDHELP http://www.child-help.be/en/ImeldaImeldahospital http://www.imelda.be/Pages/index.htmlZNAMiddelheimhospital http://www.zna.beChirurgicalmaintenance http://www.chirurgicalmaintenance.comBrusselsArlines https://www.brusselsairlines.comCurehospitals https://cure.org/uganda/DirkLeysen Dirkprd@hotmail.comFollowusonSpineCare@Cure:http://www.medicon.be/spine-carecure.html