Report on the World Spine Care (WSC) Meeting April 2-6, Gaborone and Malahapye, Botswana

Transcription

1 Report on the World Spine Care (WSC) Meeting April 2-6, Gaborone and Malahapye, Botswana This is a report on the daily activities performed during the field trip in Botswana, including the first Spine Conference held in this country as well as on WSC endeavor in general. World Spine Care: WSC is a non- profit organization established in 2009 in USA under the auspices of and in connection with the Bone and Joint Decade of United Nations. The founding and current president is Prof. Scott Haldeman, Professor of Neurology in UC Irvine, USA. The current vice- president is Prof. Margareta Nordin, Research Professor in NYU, USA. Other permanent personnel consist of Dr. Geoff Outerbridge, a chiropractor from Canada, who had been doing field work in Botswana since September 2011, establishing a WSC back clinic in the Malahapye district hospital as well as a field clinic in the village of Shoshone. There is also research personnel who had been recruited on the basis of a grant from the University of Southern Denmark, Dr. Deborah Kopanski- Giles and Ms. Maria Hondras. WSC aims to establish a self- sustaining working model for the care of spinal disorders in underserved areas of the world. To this end, Botswana selected as the pilot region for this project, pilot chiropractic clinics has been established as described above. These clinics are not only involved in the actual care of patients with back disorders but also serve as stations for research on the burden of spinal disorders in this population. There has been a pilot school- screening program established in four schools in total connected with these clinics. These clinics are estimated to become centers of education for local people as well. It should also be noted here that Memorial College of Chiropractors (Canada) have established a scholarship program, free of charge, covering the entire training of one Botswana 1

2 citizen (with the mutual understanding that this individual will return to Botswana for practice). Secondly, as most information on the economic and social burden of comes from the served areas or communities of the world, WSC aims to underscore the value of information to be provided by conducting ethno social research on this, underserved setting. And finally, a surgical leg has been planned as well. There is only one orthopedic surgeon who performs any spinal surgery at the moment. There had been several surgeons coming from different parts of the world coming but leaving after a fairly short period. This present trip has been planned as one of exploration of the feasibility of performing spinal surgery in Botswana, in both contexts; of helping the people of Botswana with their problems that require surgery and can not be managed locally, but also of establishing a surgical training program so that the local orthopedic or neuro surgeons become competent in the treatment of a vast majority of cases that may require surgery. The spine conference, mentioned above, had been introduced as an effort of surgeon (and staff) training as well. In this respect, exploration of the feasibility of performing surgery and training surgeons was the task assigned to the three surgeons in this trip; myself, Dr. Christian Etter (also representing Swiss Spine Institute) and Mr. Norman Fisher- Jeppes (also representing South African Spine Society). More information on WSC including rationale, personnel and activities can be found in the report by Dr. Haldeman to the Ministry of Health of The Republic of Botswana (Appendix 1). 2

3 Field trip: April 1: Departure from Ankara in the evening. April 2: Departure from Istanbul at 01:00 EET, arriving in Johannesburg SA at 10:00 local time (CET), arriving in Gaborone, Botswana at 16:00 local time (CET). All team including surgeons, administrators, research and field personnel and representatives from other stakeholders such as the Canadian Memorial Chiropractors College was summoned at 17:00 for a debriefing conference on WSC as well as the report to be submitted to the Ministry of Health the following day. Details of this report can be founding Appendix 1. This conference adjourned at 19:30. April 3: Departure from the hotel at 9:00 for a surgical your in the Princess Marina Hospital in Gaborone. This is the largest public hospital in Botswana and functions as a tertiary referral center for the entire country (there is another tertiary care center at Francistown, about 400 km north). Our team was briefed on the facilities and resources of the hospital by the administration upon arrival. All personnel involved had been very enthusiastic and helpful throughout the visit. Existing personnel and resources include: Doctors: 4 orthopedic surgeons (one involved in spinal surgery), 1 neurosurgeon (was not present at the time of visit). OR personnel: Competent chief of Anesthesiology, also manages surgical ICU OR: 4 theatres, 2 fairly large, 2 small. State of the art anesthesiology machines, TIVA possible. No laminar flow. Low quality OR tables that are radiolucent but cannot be adjusted for whole spine viewing. Moderate quality C- arm. Spinal surgery instruments uncertain. Microscope: Of adequate quality, no assistant visor. 3

4 ICU: 10 bed ICU with fairly satisfactory equipment. Moderately trained ICU personnel. Radiology: Digital X- ray facility. Good quality CT available. MR of moderate quality outsourced from the two existing private hospitals. Remote viewing via PACS may be possible. Blood bank: Available, the major center for blood throughout the country. Physiotherapy: Crowded PT clinic, said to be relocated to a larger space shortly. Underequipped and understaffed at this time. Surgical wards: Could not be seen due to shortage in time. Afternoon was dedicated to a visit to the Ministry of Health starting at 14:00. All the team was accepted by the Minister, Dr. Malehfo himself along with his Deputy Dr. Shenaaz el Halabi and 3 undersecretaries. Mr. Minister was presented with the WSC team after the visit to Ministery of Health, with the Minister and the Deputy Minister report of WSC over the previous year and future directions including a spine surgery program in PowerPoint format for almost one hour. Mr. Minister s response to the report and future directions was very warm, and it was agreed upon to have a new Memorandum of Understanding (MOU) for further implementation of a surgical program, with the mutual understanding that the goal this program will be to established a sustainable spinal surgery practice in Botswana rather than having 4

5 patients treated by surgeons coming from abroad, hence, based on personnel training. We have been informed of a similar program in arthroplasties, surgeons from South Africa coming for a period of several days so as to perform 10 to 15 cases on average, with the assistance of local orthopedic surgeons. It appears that the preparation and signing of the MOU similar to that of the arthroplasty program and establishment of a working program is expected to take close to one year. April 4: Departure from the Hotel for the Bokamoso private hospital in Gaborone. This is a private hospital that had been built by local insurance companies but went bankrupt after only 3 months of functioning. to be resurrected by a South African hospital chain recently. Our team was greeted by the CEO of the hospital quite warmly. Existing personnel and resources include: Doctors: 5 orthopedic surgeons (none involved in spinal surgery), one present at the time of visit, 1 neurosurgeon (not present at the time of visit). OR personnel: Could not be contacted at the time of the visit, including any anesthesiology staff OR: 10 theatres, 6 functioning, all fairly large. State of the art anesthesiology machines. Laminar flow in all theatres. Good quality OR tables that are radiolucent and can be adjusted for whole spine viewing. Moderate quality C- arm. 2 laminectomy instrument cases. Microscope: Of good quality ICU: 10 bed ICU with fairly satisfactory equipment. Alert and cooperating ICU manager, moderately trained ICU personnel. Radiology: Digital X- ray facility. Good quality CT available. A Toshiba 1.5 Tesla small magnet MR available. One radiology physician. Remote viewing via PACS may be possible. Blood bank: Uncertain, probably through Princess Marina hospital. Physiotherapy: PT clinic with mediocre physical conditions. Inadequately equipped and staffed. Said to be relocated to a larger space in the near future and better staffed. 5

6 Surgical wards: Of satisfactory physical conditions and quality. Default rooms with four beds each, VIP suites available. Moderately trained ward personnel. Departure from Gaborone after lunch (13:00), arrival in Malahapye district hospital at Tour of hospital with two orthopedic surgeons. This is a district hospital with limited resources at the present time but there exists a possibility that it will be upgraded to become a referral center in the coming years. Existing personnel and resources include: Doctors: 4 orthopedic surgeons (none involved in spinal surgery), one present at the time of visit OR personnel: Could not be contacted at the time of the visit, probably untrained. 1 anesthesiology physician and several nurse anesthetists available, not particularly cooperative. OR: 4 theatres, 2 small, 2 moderately large. State of the art anesthesiology machines. TIVA capability unknown. Laminar flow not available. Bad quality OR tables that are radiolucent but can not be adjusted for whole spine viewing. Good quality C- arm. No spinal instrument cases. Microscope: No microscope. ICU: Physically exists. NO ICU manager or personnel. No ICU equipment. Radiology: Digital X- ray facility possible but may not be available at all times. CT not available may come next year. MR not available, patients referred to either Gaborone (200 km) or Francistown (200 km). One Australian trained radiology physician. Remote viewing via PACS a remote possibility. Blood bank: None existent. Blood ordered from Gaborone for elective surgeries. Physiotherapy: PT clinic non- existent in reality. Surgical wards: Of less than satisfactory physical conditions and quality. Default rooms with 6 to 8 each in an open ward concept. Hygiene less than satisfactory, untrained ward personnel. 6

7 April 5: Mahalapye Spine Care conference in the Cresta Malahapye Hotel starting at 9:00 (program attached, Appendix 2). This conference is endorsed by the Ministry of Health as well as the Archbishop Perpetual Desmond Tutu. There were over 100 registrations of a wide variety of health workers including but not limited to surgeons, MDs, chiropractors, physiotherapists and nurses. Most of these people stayed till the very end of the conference and were very attentive and enthusiastic Malahapye District Hospital about having such a conference in their country. Feedback from the conference is very positive; it is quite likely that the conference next year (WSC team already started planning for) will be much larger in terms of attendance, attracting people from the neighboring countries as well. April 6: Field trip to Shoshong, approximately 30 km from Malahapye. There is an outpatient chiropractic clinic established within the premises of local clinic in this village. It is a container with 6 rooms, two used for examination and treatment, two offices, one bath and one storage and archive room. Dr. Outerbridge and one volunteer (when 7

8 present) see patients (2 new patients per day) and deliver treatments in this setting 3 days per week, and in the clinic in the Malahapye district hospital on the remaining two days. WSC team in front of the Shoshong field clinic 8

9 April 7-8: Return trip to Ankara. Deductions and recommendations: World Spine Care: This is a non- profit organization aiming to provide Back Health Care to the underserved communities throughout the world. As mentioned above, it is supported by the Bone and Joint Decade and several NGOs, with the prospect of obtaining grants from prominent international foundations. Future plans include establishing similar field offices and clinics in Tanzania and the Dominican Republic. In addition to being a noble cause there are two aspects of this endeavor that need to be underlined here: 1. Introduction of musculoskeletal disorders generally and back and neck disorders specifically as public health problems. This approach is based on a Global Burden of Disease 2010 Report (Lancet 2012, 380; see Appendix 1) specifying that the global burden of disease load has shifted from communicable diseases (HIV, Tb, Malaria etc.) to non- communicable diseases. Of these, musculoskeletal disorders are second only to coronary artery disease in terms of disability adjusted life years. This approach is new and unique and is being implemented only by WSC as to my knowledge. 2. Introduction of a holistic approach to spine care in underserved communities. Having mostly based its services on chiropractics so far, WSC now takes a step forward as a facilitator of total spinal health care by incorporating physiotherapy and surgery. This is a very promising approach in my opinion, as it would enable the organization to provide care in layers ranging from field clinics to fairly complex spinal surgery to post- surgical care. 9

10 Republic of Botswana: I have to emphasize that I was very impressed by this country overall. It has fairly well organized community services with very impressive infrastructure. Although the priority for health services will remain focused on the communicable diseases (there is a 17% rate of HIV positivity), people (including administrators) are very positive, fairly well educated and eager for improvements in their health care system. Having been in Botswana now, I realize that this would be an ideal setting for the implementation of such a program as outlined above. It has the will and resources; and it is a blank sheet in terms of spine health. Support from the government is an absolute advantage. Prospects for Spinal Surgery: Exploration of the feasibility of having spinal surgery performed in the Republic of Botswana was the very purpose of the present field trip for the spinal surgeons in the team. This needs to be evaluated in three different aspects: 1. Establishment of a referral system for spinal surgery: The need for establishing a referral system arises from the current de- facto and proposed future structure of primary spinal care. In most developed countries primary care is being provided by medical doctors (GPs and/or family practitioners) who are fairly knowledgeable in the selection of patients to be referred for surgery. However, in the proposed model for Botswana, field services will mostly be the responsibility of medical practitioners (including chiropractors) who are not particularly familiar with the prospects of spinal surgery. Based on this, it would be advisable to establish realistic guidelines for referral and start educating local medical personnel on these guidelines. 2. Feasibility of Spinal Surgery in Botswana: With the present infrastructure as outlined above, spinal surgery can certainly be performed in the Republic of Botswana. In this respect, the question here is not 10

11 whether it would be feasible, but rather, what types of surgery would be feasible, at the present time as well as in the future. A stratification of surgical procedures is necessary for this purpose; my proposition to this end is as follows: a. Basic spinal surgery: Includes primary surgeries for i. cervical and lumbar disc herniations, ii. single level lumbar and cervical spinal stenosis (including degenerative spondylolisthesis in the lumbar spine) (including posterior instrumentation) iii. posterior surgery for thoracolumbar spinal trauma iv. posterior surgery for cervical spinal trauma v. posterior surgery for spinal infections (including instrumentation) vi. in- situ fusion +/- instrumentation for spinal deformity b. Advanced spinal surgery: Including: i. primary posterior and/or anterior surgery for idiopathic spinal deformity including scoliosis and Scheuerman s kyphosis ii. posterior surgery with posterior (only) column osteotomies iii. primary anterior surgery for metastatic disease of the spine (including instrumentation) iv. primary anterior surgery for spinal infections v. primary anterior surgery for cervical and thoracolumbar trauma vi. multi- level spinal stenosis in the cervical and lumbar spine (including instrumentation) vii. vertebroplasty, kyphoplasty viii. dynamic spinal instrumentation including disc arthroplasty ix. minimally invasive spinal surgery x. surgery for tumors of the spinal cord xi. surgery for infections of the spinal cord c. Complex spinal surgery: Including: i. any spinal surgery that requires two column osteotomies 11

12 ii. adult deformity surgery of any kind iii. deformity surgery with sacro- pelvic extension iv. revision anterior or posterior surgery of any kind v. surgery for primary tumors of the spinal column Technical and personnel requirements for these will be as follows: 1. Basic spinal surgery: i. Specialist in orthopedics or neurosurgery capable of providing assistance and following patients after surgery ii. Radiology with the capability of digital x- rays, CT and MRI iii. Scrub nurse familiar with spinal fusion and instrumentation iv. Operating table with cross table imaging ability v. C- arm vi. Blood bank or possibility to reserve blood for transfusion vii. Operating microscope viii. Instruments and implants for posterior spine surgery ix. Nursing personnel capable of following patients after surgery 2. Advanced spinal surgery, in addition to the requirements of basic: i. Experienced anesthesiology team to perform hypotensive anesthesia and total IV anesthesia ii. Blood bank iii. Instruments and implants for anterior and posterior spinal surgery iv. Intraoperative neuromonitorization v. Intensive care unit (ICU) vi. In house physiotherapy personnel experienced in mobilization of patients following spinal surgery 3. Complex spinal surgery, in addition to the requirements of advanced: i. Experienced anesthesiology team familiar with patients with comorbidities and excessive blood loss during surgery 12

13 ii. Blood bank capable of preparing fresh frozen plasma and thrombocyte suspensions iii. Intraoperative blood salvage and bleeding control capabilities (cell saver, agents with thrombin) iv. Cardiovascular surgery grade ICU v. Ability of in house experienced internal medicine, pediatrics, cardiology and hematology consultations Current situation of the three candidate hospitals: Mahalapye district hospital: Very limited possibility of performing basic spinal surgery safely. In addition to the requirements for basic spinal surgery listed above, the condition of surgical wards and operating theatres will need to be improved substantially. Princess Marina Hospital, Gaborone: Present capability of performing basic spinal surgery, may be upgraded for advanced spinal surgery with minor improvements. Bokamoso Hospital, Gaborone: Present capability of performing basic spinal and advanced spinal surgeries. Advanced surgeries will hinge on the availability of trained personnel rather than hardware. As a conclusion for the feasibility of establishing a spinal surgery program in the Republic of Botswana; my first impression is quite positive but there are very important details that need to be sorted out. Contact channels for constant discussion and collaboration between the local personnel and (candidate) volunteer spine surgeons need to be established as soon as possible for further discussions on these details. Training of personnel for spinal surgery: There are two possible approaches for this problem. One is to train the personnel including surgeons, OR personnel, scrub and circulating nurses, ICU and floor 13

14 personnel as surgeries are being performed by teams imported from outside. My understanding is that this had been the practice in the arthroplasty model of Princess Marina Hospital. This approach will be effective for an objective evaluation and possible improvement of the resources in the involved hospital(s) and optimal care for the patients to be recruited into this project. It also has the advantage of establishing contact with a very large group of spine health staff in a limited time frame. On the other hand, its effectiveness as an educational model may be limited because Low back pain is more common in woman in of this very limited contact time between Botswana as most physical labor is performed local personnel and volunteer surgeons. In by them addition, establishing a post- operative care program of adequate quality may be very difficult with this model. The second approach would be to establish scholarship programs to train spine specialists in areas with better resources. This has already been established for one person to be trained as a chiropractor, for whom the tuition has been kindly waived by the Canadian Memorial Chiropractic College. A scholarship from the Republic of Botswana will cover the daily expenses of this person, with the mutual understanding on his or her returning to Botswana following the completion of the program. Similar programs may easily be established as spine fellowships (for orthopedic and neurosurgeons) in Europe and North America. In m opinion, adaptation of both approaches is not only very feasible, but also may be the best way of establishing a self sustaining spine care program in the Republic of Botswana, or any other country with similar will and resources. 14

15 Conclusion: WSC program appears to be promising in establishing a sustainable spine care program in the Republic of Botswana. It has the distinct advantages of defining and presenting spinal health as a major public health problem and proposing a multilayer holistic approach for the local solution of his program. I do not think that I am in a position to provide recommendations on the possible role(s) of the European Spine Society in this endeavor but I think this report will be of help to the Excom in decision making. Submitted respectfully by Emre Acaroglu MD 15