OSS Activities Report 2010

Operation Straight Spine Activities Report 2010

Ramakrishna Mission Seva Pratishtan Kolkata, India
January 01-15, 2010

January 1st:
The US contingent of the OSS team departs from JFK airport, New York at 16:00 on Air India. Team members consist of; spine surgeon Jeff McConnell, MD; Lehigh Valley Hospital Neuroscience unit head nurse, Holly Tavianini, RN; surgical scrub nurse from St. Luke’s Hospital, Marion DeMillio, RN ; neuromonitoring specialist, Ms. Hillary LeClair; and Globus Medical representative, Mr. Larry Nelson.

January 2nd:
Connecting flight from New Delhi to Kolkata is delayed for four hours due to severe fog in Delhi (not an uncommon occurrence this time of year).

January 3rd:
Finally arrive at Kolkata airport at 01:15. All baggage accounted for and clearance through Immigration and customs with no difficulty. Our party is met by Bitu Debnath (sister of Dr. Ujjwal Debnath), her friend and drivers for transport to Oberoi Hotel. Two vehicles are required to transport the team and all their bags. A small glitch occurs on the way to the hotel when one car is stopped by Kolkata Police at a make-shift road block. This is presumably a random stop for police to extort money for most trivial (and often contrived) infraction of the rules. It turns out our driver has an invalid driver’s license. A prime opportunity for the police to take advantage of the situation, but after some negotiating and the “fine” of 4,000 Rs is paid we are happily on our way again.

We check into the Oberoi Grande Hotel around 02:30. No one is particularly tired due to the time change and the fact most us slept on the plane. So we stay up and chat about the excitement of being in India and the challenges facing us over the coming weeks. For two of the team members, it is their first time in India. Most finally go to bed around 05:30.

The team meets for Sunday brunch around 11:15. Two vehicles and Dr. Ujjwal Debnath arrive at the hotel to transport the team to the Ramakrishna Mission Hospital. We begin sorting through boxes of supplies in the store room to gather enough consumables for the planned surgical cases on Monday. As was the case last year, our 13 boxes of fresh supplies shipped from the US are held up at the customs office. Thankfully we had enough supplies in the store room left-over from last year to get us through the first few cases. The boxes were caked in a layer of dust so we had to do a little house-cleaning as well. We also learn that the Globus spine instruments and implants have not yet arrived in Kolkata – again an issue with the customs office. Mr. Nelson frantically works the phone, talking with the Globus India team to find out when the implants might be available. We located our general and spine surgical instrument sets and had them divided into two trays, wrapped and sent to the autoclave to prepare for the surgeries on Monday.

We are all a bit nervous not knowing if we will have implants for the cases tomorrow, but with little else to do, we head back to the hotel. We all hope and pray things work out.

The area immediately surrounding the hotel is a large market district so the team ventures out for a little shopping. The streets and the market are clogged with people. We negotiate our way across the busy intersection to Eliot Park, an expansive area of open ground in an otherwise congested city. We walk past fields crowded with people playing cricket and soccer to the other end of the Park to the Victoria Monument. Kolkata used to be the capital of India under British rule and the Victoria Monument was built in honor of Queen Victoria’s 50 years on the thrown. It is a magnificent marble building with a towering white dome at the center. A ticket was required to enter the Monument but since the que was so long for tickets we abandoned the idea. We took a taxi back to the hotel as it was a rather long walk and jet lag was catching up.

We ate dinner at the Thai restaurant in the hotel. The team members from the UK finally arrive at the hotel around 20:30 after also being delayed by the Delhi fog. The four team members from the Guys and Thomas Hospital in London include anaesthetists Drs. Neena Seth and Caroline Davies, operating theatre Sister Marian Barry, and anaesthesia technician Sister Jane Holley. We exchange greetings and the new team members get to know each other over drinks at the pub.

January 4th
We ate breakfast at 0800 and got the disappointing news that our 13 boxes are still in customs and that the Globus equipment will not arrive today. Mr. Nelson makes arrangements with local Globus vendor to bring implants from local inventory for our one instrumented case in the afternoon.

Dr. Debnath and Dr. McConnell attend spinal clinic to screen potential surgical candidates and see follow-up cases. One patient is a follow-up from March 2009 mission trip. Ankita Panja is a 3-year old girl who came to us very ill with tuberculosis of the spine. She could not walk. She was losing weight . TB had destroyed the 11th and 12th thoracic vertebrae and the MRI showed a large epidural abcess extending to L1 with extraspinal abcess involving both psoas muscles. We operated front and back, draining the abcesses and stabilizing the spine with cervical spine instrumentation and rib grafts. Her follow-up showed her to be neurologically normal, happy, healthy and thriving with a stable, straight spine fused from T9 to L2. Great to see her!.
By the time the team gets organized and enough supplies put together, we did not start our first case in the Operating Theatre until after 12:00.

Case #1: 40 year old man with back and right greater than left leg pain. Diagnosed with right L3-4 disc herniation and L4-5 spinal stenosis. Surgery consists of L4-5 decompression and L3-4 hemilaminotomy and discectomy on the right.

Case#2: 55 year old female with a L4-5 lytic spondylolisthesis, bilateral foraminal stenosis and right greater than left leg pain. Procedure consists of decompressive laminectomy, TLIF with 7mm PEEK cage and ProTex pedicle screws and rods.

Team finally finishes in the OT at 20:30 and everyone returns to hotel for late dinner.

January 5th
The boxes of supplies from the U.S. are still not available. Luckily we have enough supplies from last year to get through the day.

Case #3: 60 year old female with two level spndylolysis at L3 and L4 with grade-2, L4-5 spondylolisthesis and spinal stenosis. Congenital fusion of L5-S1. Surgery consists of L4-5 TLIF with PEEK cage, posterior fusion and instrumentation L3 to L5.

Case #4: 12 year old boy with congenital lumbar kyphoscoliosis due to left L3 hemivertebra. Surgery performed with posterior excision of L3 hemivertebra and posterior fusion with instrumentation L2 to L4.

Our second day in surgery again concludes late at 20:30. Back to hotel for well deserved rest.

January 6th
We have an unanticipated day off due to a holiday observed by the Ramakrishna Mission. It is apparently the birthday of the hospital founder’s wife. The team takes the opportunity to locate one of our patients who had surgery during our trip in 2009.

Julie Sharma was a 9 year old girl who presented to the OSS team in extreme pain and unable to walk with severe weakness in her arms and legs. She was suffering from tuberculosis of the cervical spine. Julie’s social situation was equally dire. Her mother was dead, her father, an unemployed farmer, could not afford to care for her and gave her up to a family to work as a house servant. On admission to the hospital her x-rays and MRI revealed destruction of several cervical vertebrae, kyphosis of the neck, epidural abcess with spinal cord compression and a large pre-spinal, retropharyngeal abcess. Her spine was stabilized posteriorly with lateral mass screws and rods from C2 through C6 followed by anterior drainage of the retropharyngeal abcess, evacuation of the epidural abcess, decompression of the spinal cord, multi-level cervical corpectomy and reconstruction with fibular autograft. Postoperatively she did well, but follow-up was short. The entire team knew Julie’s long-term survival would depend on her receiving appropriate medical treatment with 18 months of 4-drug chemotherapy to eradicate the tuberculosis. She remained at the mission hospital approximately three weeks and arrangements were made for her continue care through the HOPE Foundation, Ireland.

On Wednesday morning the OSS team drove to the headquarters of the HOPE Foundation in Kolkata. There we met the director, got a tour and saw some of the small children being cared for in a day program. We thought we would see Julie there but were informed she was actually living in an all-girls home on the other side of town. We returned to the RKMSP hospital and made rounds on the surgical patients from Monday and Tuesday.

After lunch we returned to the HOPE Foundation and were escorted across town to the group home where Julie Sharma was living. It was a 4-story home, a very clean and safe facility housing 60 girls ages 7 to 13 years. Julie looked wonderful and what a beautiful smile! She had gained weight and had no complaints with her neck. She was attending school, learning to read, write and draw. She had made us a card ahen she knew we were coming. It was sad to have to say goodbye as the entire team had great affection for her, but we were all happy to see her healthy, happy and safe.

That night the team enjoyed a traditional West Bengal cuisine, served in clay pots and dishes at the Kewpie Resataurant in old Kolkata. We also received good news that at least a portion of the Globus implants would finally be arriving from Chennai. However, still no word on the boxes of supplies from the U.S.

January 7th
Back to work.
Case # 5: 30 year old male with left leg pain and L5-S1 disc herniation. surgery consisted of left L5-S1 hemilaminotomy and discectomy.

Twelve of the thirteen boxes of supplies were finally cleared through customs and delivered to the hospital. They arrived just in time as we were running out of many things. The team spent the time between cases unpacking the boxes and transporting supplies to the OT.

Case #6: 4 year, 18 month old male with congenital kyphosis at T10. Underwent posterior fusion without instrumentation T8 to T12.

While the anesthetic nurses recover the surgery patients in our makeshift recovery room in a converted OR room, the rest of the team makes rounds on the patients. We find we must constantly remind the nursing staff in the hospital to get the patients out of bed. Holly Tavianini, RN spends a lot of time instructing the nurses and patients in how mobilize. The hospital is very rudimentary . The beds are simple cots that do not raise up or down and have no side rails. There is no physical therapy. All the patients are noted to be doing well however.

January 8th
Case #7: 19 year old female with severe back pain and bilateral leg pain. X-Ray and MRI demonstrate destruction of the L5-S1 disc with an associated large tuberculous abcess in the pelvis. Surgery consisted of an anterior, retroperitoneal approach with drainage of the abcess, debridement of the L5-S1 disc space and placement of a 9mm titanium Sustain cage with Tricalcium phosphate and BMP. Posterior approach performed for placement of L5-S1 pedicle screws.

After surgery completed Dr. Debnath and Dr. McConnell saw a number of patients in the clinic who were potential surgical candidates. First was a 14 year girl with a thoracolumbar scoliosis who we booked for the following week. The second was a 28 year old woman with a grade 2, L5-S1 spondylolisthesis who is also added to the list for the following week. The third patient was a 37 year old male who works as a nurse in the OR at the hospital. He has a large C5-6 disc herniation with cord compression and early myelopthy. He is encouraged to have surgery however he feels he cannot get time off of work.

January 9th and 10th
The OSS team takes the weekend off and travels to Puri, south of Kokata. We visit the ancient sun temple of Konark and walk the beach on the Bay of Bengal. It was a good time for the team to refresh before more surgery.

January 11th
Because of the busy holiday season in India the OSS team could only lodge at the Oberoi hotel for a limited period of time. The team and all the luggage are moved to our new accommodations at the Tolleygunge Club. The move provided us time for only one surgical case on Monday.

Case #8: 73 year old male with severe spinal stenosis at L3-4 and L4-5 with a degenerative spondylolisthesis at L4-5. Treated with decompression at both levels and TLIF with pedicle screw instrumentation at L4-5.

Dinner on Monday evening was at the home of Neena Seth’s brother.

January 12th
Case #9: 70 year old female with spinal stenosis at L4-5 and L5-S1. Surgery consisted of decompression at both stenotic levels.

Case #10: 3 ½ year old male with severe congenital scoliosis. Several vertebral anomalies including a hemivertebra, and an absent rib on the right. Surgery consisted of posterior T5 hemivertebra resection with posterior fusion and instrumentation using Protex CT from T3 to T7.

Following surgeries we made rounds on all the patients. Everyone is doing well. Return to the Tolleygunge Club for dinner and bed.

January 13th
Began the day with rounds in the pediatric ICU to extubate the baby boy after his congenital scoliosis correction yesterday. Extubated well – he is awake, moving all extremities and crying for his mother. Doing better than expected after such a big surgery.

Case #11: 13 year old female with right thoracolumbar scoliosis with significant coronal plane decompensation. Surgery performed with Revere Deformity set – posterior approach using all fixed angle pedicle screws and dual rods from T9 to L2. We used the derotation set, linking the screws at each vertebrae together with cross connector bar then derotating each vertebra individually. Excellent correction was achieved.

Case #12: 28 year old female with Grade 2, lytic, L5 – S1 spondylolisthesis. Experiencing both back and L5 nerve root mediated leg pain. Surgery consisted of TLIF with 7 mm PEEK cage. Very difficult to place L5 screws due to extreme medial angulation of 40-45 degrees. Would have been a good case for percutaneous pedicle screws using Revolve as it would be easier to get medial angulation of screws at L5 under X-ray guidance. Although difficult, surgery went well.

Following surgeries made rounds on patients in the various wards throughout the hospital. Again, everyone looks good and are pleased with their results. Kudos to the OSS team.

January 14th
Case #13: Our second patient from the week before, the 55 year old woman with spondylolisthesis, developed right leg pain when she began to mobilize out of bed. A CT scan revealed possible pedicle violation of the right L5 screw. She returned to the OR for a re-exploration we found that the medial wall of the right L5 pedicle had fractured and pushed inward encroaching onto the L5 nerve. Luckily we were able to reposition the screw and salvage the procedure.

Once again we made rounds on all patients with the orthopaedic resident staff. Other members of the team began to gather our instruments to be cleaned and sterilized for long-term storage.

January 15th
The final day. It has been a stressful and exhausting yet rewarding experience. We check out of the Tolleygunge club after breakfast and take the cars to the Mission Hospital. We spend most of the morning packing up all unused supplies and transporting them to the store room for safe keeping until our return visit (date to be determined). We receive our surgical instruments from the autoclave and return those to the store room. Ironically the final shipment of the majority of the Globus implants and instrument sets finally arrive. The boxes are placed in the store room with the rest of the gear.

We met with the head Sister for the Operating Theatre to present her with a donation of 8,000 rupees to be used for their upcoming Puja (religious celebration) that the surgery department is organizing for the staff at the hospital. She is very appreciative for the donation. We in turn share our appreciation for she and her staff who were most accommodating and helpful throughout our stay.

The OSS team makes final ward rounds on all the patients. Very emotional for the team. Several of the patients and their families bend to touch our feet – a traditional West Bengal sign of respect and appreciation. They call us “Gods”, but of course we are not worthy of such praise. A simple smile on a patient’s face is all we need to remind us why we came here. All the patients are doing well and they ask when we will return again. The entire team is appreciative of the opportunity to have made a difference in the lives of those patients we came in contact with during our short stay in Kolkata.

We depart for the airport around 3:30 in the afternoon. Sad to leave but glad to be going home.

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