Uganda Charitable Spine Mission

July 26th-August 7th 2009 Trip Report

http://www.firstgiving.com/UgandaSpineSurgeryMission2009-2010

Team; Isador Lieberman MD, Mark Kayanja MD, Selvon St.Clair MD, Donna Sustar, Brian Failla, Michael Silverstein Location; Mulago Hospital, Kampala Society Sponsors; Health Volunteers Overseas (Orthopedics Overseas), Scoliosis Research Society (Global Outreach Program) Corporate Sponsors; Medwish Inc, Globus Spine Inc, Synthes Spine Inc Local Physicians Dr. Deo Bitariho (orthopedics-Mbarra), Dr. Malan Nyati (orthopedics-Mulago), Dr. Geoffrey Madewo (orthopedics-Mulago), Dr. Titus Beyeza (Chief Dept. of Orthopedics -Mulago), Dr Emanuel Munyarugyero (anaesthesia Mbarara)

 To whom it may concern, The 2009 Uganda Spine Mission Team with gratitude and anticipation for the future, respectfully submit this trip report outlining the accomplishments and details of the July/August 2009 trip. We would like to first acknowledge the support of the many, who with their contribution allowed us to once again accomplish so much; Globus Spine Inc. provided the full breadth of instruments and implants to allow us to treat the entire spectrum of spine pathology, Medwish Inc. was yet again a source of vital medical equipment which proved indispensable during this mission, The Operating Room Personnel and Hospital Staff at Cleveland Clinic Florida were dedicated to collecting discarded items for use in Uganda, All our generous friends and family who took the time to generously donate to the mission via the website, and as always, the staff at HVO and the staff at SRS who were active supporters and a pleasure to deal with. This team consisted of the veterans (IHL, SStC & MK) and the rookies (DS, BF, MS). There was a clear distinction in emotions and anticipation between the two. The veterans knew what was ahead and hoped for a productive yet uneventful mission. The rookies were eagerly curious to determine if the stories and experiences they heard were true. Once entrenched in the work flow, the entire team gained in their unique way a sense of purpose, dedication, insight into their own personalities, their own beliefs and fully experienced the devastation of neglected spinal pathology and the extent of care needed. In retrospect this mission was by far the most productive, most organized, and seemingly best accepted by the local medical establishment. At Mulago hospital the dedicated spine ward and operating theatre were open and functional. Still limited by North American standards, however, clean, sound and well equipped. Despite the new facilities we once again encountered limitations of time, of equipment, and of personnel. The issues of sterilization returned to hinder us over and over due to the lack of fresh water for sterilization. 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. The team took the challenge and each member functioned admirably keeping their utmost regard for the patients well being.

 Arrival (July 26, 2009) The team began the journey split, half coming from Fort Lauderdale and the other half from Cleveland. Initially, we were to meet in Detroit and travel together to Amsterdam, where we had a connecting flight to Entebbe. Due to weather issues in Florida, the group met in Amsterdam instead. But, after more than 20 hours of traveling, we arrived in Uganda with excitement and anticipation for what was ahead. The city reminded a few members of the group of something they had seen on the Travel Channel. Upon arrival to the Golf Course Apartments, we unloaded the vehicle and established a plan for the first day. Day 1 (July 27, 2009) The day started off with a breath of fresh air and an early breakfast. Surrounded amongst colorful scenery, the team enjoyed a breakfast of fresh orange juice, pancakes, egg whites and coffee. After we had some fuel for the day, we loaded supplies in the van and headed to Mulago Hospital to set up for the day. We meet with Dr. Titus Beyeza, Head of the Orthopaedics Department. He welcomed us with a warm smile and was happy for us to be there to provide help as well as educational opportunities. Both the veterans (IHL, MK, SStC) and rookies (BF, MS, DS) spoke with Dr. Beyeza about their excitement for being able to help the community. Dr. Beyeza explained to the team that there has been an increase in interest amongst the residents in pursuing spine surgery as their field of specialty. This made the desire to provide education even more personal. To educate future spine surgeons in Uganda is a key component of our mission. Following our meeting with Dr. Beyeza, we proceeded to the newly opened spine ward, where we inspected the recently opened operating room dedicated to spine surgery. (See Figure 1) Bolstering our enthusiasm was the fact that the operating room looked functional clean well stocked and ready to use. We then moved on to the spine ward to visit with patients ranging from young children to the elderly. (See Table 1) We quickly established a plan of action for those patients that were deemed operable and others that would recover better with rehabilitation.

Figure 1: Inside the new Spine Ward. Standing (L to R)- Silverstein, Lieberman, Sustar, Kayanja, St. Clair, Failla Table 1: patients seen on the first day of clinic and ward rounds. Table 1: Mulago Spine Ward (Seen on July 27, 2009) Name Age Sex Diagnosis Treatment M.E 11 M Lesion at T11 Previous surgery/CT scan for update and reassess in 1 year S.B 15 M L2/3 Disc Herniation No further surgical intervention M.O 57 M Lesion at C6 Rehabilitation S.M 43 M C5/6 No further surgical intervention; Spondylolishesis reassess in 1 year M.A 28 M T3/4 disc herniation No surgical intervention; reassess in 1 year F.S 30 M C6/7 No further surgical intervention; Spondylolishesis reassess in 1 year G.M 60 M T12 mass T10 Thoracotomy, T12/L1 distectomy/anterior release with rib graft R.W 6 M Unknown Reassess in one year parenthesis A.S 12 F C6 Stenosis No further surgical intervention J.L 41 M T12/L1 kyphosis No further surgical intervention; reassess in 1 year

 E.M 12 M Spinal cord compression at T5/6 Thoracic lesion; Spinal TB Lumbar disc herniation Cervical fracture Thoracolumbar kyphosis Congenital scoliosis and Epidural abscess L4/5 disicitis Congenital scoliosis L5/S1 disc herniation Congenital Scoliosis Facet arthritis Potts disease Localized kyphosis T10 osteylolitis Mild scoliosis No further surgical intervention; reassess in 1 year No surgical intervention; reassess in 1 year No surgical intervention No further surgical intervention Brace and reevaluate in a year Unilateral laminectomy T7-T11 and Tb biopsy No further surgery, exercise take NSAIDs as needed T7-L1 in situ fusion L5/S1 laminectomy Follow up in 1 year No surgery, exercise, NSAIDs as needed Follow up in 1 year Follow up in 1 year Follow up in 1 year Follow up in 1 year

A.B E.A B.K J.N S.N

28 54 45 45 35

M F F F F

G.M J.K G.M M.N A.Z. N.K J.N I.I P.T

40 7 19 12m 50 14 2 16 19

F F M F F M F F F

After seeing patients in both the ward and clinic, half of the team triaged the patients for surgery for the first week while the others began sorting out the instruments for surgery. There were already 14 surgeries scheduled. Both the new Spine operating theatre and the Old Mulago Orthopaedic operating theatre would be used to perform surgery. The tentative plan included surgery in the Spine OR on Tuesday through Friday and the Orthopaedic OR on Wednesday and Thursday. The equipment and patients would have to be shuttled back and forth between the two sites. The first day brought emotions of both excitement and regret to the team. Patient B.N. had surgery by the team that came in March 2009 to correct his scoliosis of 110o (See Figure 2a). He was very happy to have had the surgery and showed a quick recovery. A thoracoplasty (further resection of protruding ribs) would be planned for next year. On the other hand, two young patients who were planning on coming to Mulago Hospital for assessment and surgery, from the Childrens Home, were informed that surgery would not be an appropriate option for them.

Figure 2a: Post-operative visit, patient B.N. Another patient we saw during clinic was N.K., a 14 year old male. He had Potts disease (tuberculosis infection of the spine) that had wreaked its damage and can not be corrected with surgery. Performing an operation on him would only increase his chance of death without greatly improving his quality of life. At this point in his life he was still able to play sports and keep up with his friends. (See figure 2b)

Figure 2b: Patient N.K. As our time at Mulago hospital came to an end for the day, we quickly were reminded of just how precious life is and how a worldwide effort is needed to alleviate the suffering from debilitating spinal illnesses. A short drive back to the apartment turned into a journey of despair. The veterans quickly noticed the increase in the volume of cars and resultant traffic in Kampala over the four previous missions. Apparently many discarded vehicles from Europe and North America are being shipped to Uganda and are available

 relatively inexpensively compared to used vehicle prices around the world. The combination of vehicles, animals (cows and sheep), boda bodas (scooter taxis) and no traffic signals or stop signs combine to make driving in Kampala a whole new life threatening experience. Despite the harrowing 1.5 mile drive back we ended the day with a refreshing dinner, and tall tales, which went late into the night.

Day 2 (July 28, 2009) This was the first day of surgery at Mulago hospital. Two were scheduled for the spine theatre (Patients G.M. and S.N.). Dr. Lieberman presented an instructional lecture on adult spine trauma to the residents and orthopedic professors of the medical school. While he was speaking the team was quickly trying to organize the medical instruments and supplies for the scheduled surgeries. Preparation of some of the supplies were delayed due to the common water issues which have we experienced during our past missions to Mulago hospital. Once the water became available, the autoclave was run to sterilize the instruments for the day. This delayed us somewhat and we did not begin the first surgery until about noon. This would have a lingering effect. Patient G.M. was the first patient to undergo surgery. Patient G.M. was a 60 year old man who has been bedridden and suffering from severe back pain for the past few months. He was started on medication for TB the previous week. The MRI scans that were reviewed, revealed an epidural mass at the T12 region of the spine. The surgery lasted 5 hours and consisted of a T10 thoracotomy (removal of rib), with an anterior T12/L1 release, decompression and reconstruction. His rib was used as a bone graft to fill in the cavity. There was not a large amount of blood loss during the procedure. The mass that was removed was sent off to pathology and it was predicted that patient G.M. had either TB or some other spinal osteomyelitis (bone infection). On day 1 post-op, the patient stated that he was not in much pain but he still had some drainage from his chest tube. Even though he was bedridden, he had a large smile, and was enthusiastic about his treatment and prognosis. (See Figure 3) He was instructed on the use of an incentive spirometer (a breathing exercise device, supplied by Medwish) and to sit up in bed. A few days later he was able to move to a wheelchair.

Figure 3: Patient G.M. (L) Being examined by Dr. Isador Lieberman, (R) sitting comfortably for the first time in months In between our surgical cases of the day, patient K.N. was brought into the spine ward to be seen by the team. She was a 54 year old female that was in a motor vehicle accident and paralyzed due to a severed spinal cord at T10. As her spine was unstable the prescribed treatment for K.N. was a reconstruction and fusion with rods and screws from the T9 to L1 spinal levels. (See figure 4)

Figure 4: K.N. in her wheelchair being evaluated. The second surgery of the day began in the early evening following our first case. Patient S.N. was a 35 year old female that was diagnosed with congenital scoliosis. She stated that the lower back pain she has been having for a good portion of her life has gotten progressively worse in the past 7 years. For the past month, she has been unable to move her legs. An epidural abscess was found at the 8th thoracic level. During the surgery, a unilateral hemi-laminectomy was performed from T7 to T11. In addition, a T8 biopsy was taken to identify the

 abscess. Post-op on day 1 she stated she had a burning sensation in her legs and was still unable to move her legs. The results from the pathology lab had not yet returned by the time we left Mulago Hospital, so the doctors from the hospital would contact us when they received the results.

Day 3 (July 29, 2009) Prior to this days scheduled surgeries, we saw a few new patients who heard we were here in town to provide care. Patient A.A. was a 19 year old male who had surgery during the last mission trip in April 2009. He had a fusion at L4-5 for spondylolisthesis. One of the screws was creating some pain for him, but he is still in the recovery phase from his surgery. It was planned for him to follow up with the team in a year to reevaluate him then. (See Figure 5)

Figure 5: Post-operative images of Patient A.A. Unfortunately for the two other patients we saw that morning, surgical treatment was not an option. Patient S.D. was a 3 year old female who was diagnosed with kyphoscoliosis. The team of doctors decided to follow up with her next year to see if her condition has progressed. The other patient, E.M., was a 33 year old female with pain throughout her arms and legs along with difficulty walking. Due to her myopathy (muscular disease) not coinciding with a spinal condition, a metabolic or rheumatologic disease was suspected. She was advised to see a rheumatologist and get tested for a vitamin B12 deficiency. The first scoliosis case of the trip was rewarding to both the team and the patient. J.B. was a 15 year young female with a progressive idiopathic scoliosis. Her curve measured 40 degrees and had progressed steadily from 2005. The proposed treatment was a T6-L1 posterior instrumentation correction and fusion. The surgery took about 6 hours to complete and resulted in a significant correction with no peri operative or post operative complications. (See figure 6)

Figure 6: Patient J.B. Post-op from first surgery. The afternoon case was a 17 year old female whose planned surgery involed two stages. Patient A.N. had a severe case of scoliosis with a 105o right-sided curvature. This left her with a drastic curvature and limited her daily activities. The first stage consisted of entering through the rib cage (going from in front) and releasing the vertebral bodies of T7 to T10. The second stage would occur the following week to correct and stabilize the spine from behind. (See figure 7)

Figure 7: Patient A.N. (L) Pre-operative scoliosis, (R) Post-op recovery in the spine ward.

 Day 4 (July 30, 2009) The first surgical case of the morning was pushed over from the previous day due to time constraints and unsterilized equipment. J.K. was a 7 year old female patient that was diagnosed with congenital scoliosis. The surgery did not require instrumentation, but used her own bone and growth potential to realign her spine over time (in situ fusion). J.K. was a real trooper! She handled the surgery very well for her age. (See figure 8)

Figure 8: Patient J.K. (L) Pre-operative image, (R) Post-operative image Our next case was a 19 year old male, G.M., who was complaining of mostly leg with some back pain. His symptoms were a result of his congenital (born with it) stenosis (narrowing of the spinal canal) and a chronic disc herniation at the L5/S1 spinal level. A laminotomy and microdiscectomy was performed to correct his problems. He handled the pain well but his body habitus was a major limitation to his rehabilitation. (See figure 9)

Figure 9: G.M. being evaluated by Drs. Lieberman and Kayania

 Throughout the trip we encountered many unfortunate patients who we just could not help. Patient A.T. was a 4 month old female that has both neurological (brain) and spine problems. She had travelled with her desparate mother from one of the distant villages. The cause of her symptoms is simply not known and at this young age her prognosis for any meaningful function is limited. We recommended she return in one year for further evaluation. (See figure 10)

Figure 10: Patient A.T. Day 5 (July 31, 2009) Today was a very rewarding day for the team and patients. The day began with checking the post operative patients on the spine and orthopedic wards. All of the patients were doing very well following their surgery and neither the patients or the team had encountered any major issues. During this visit we did however notice how the local nursing staff are reluctant to dispense any pain medications. The prevailing sentiment is that using pain medication will cause one to become addicted. The team had a difficult time understanding the sentiment especially knowing the extensive nature of the surgeries we performed. In response we made arrangements to have medications dispensed either by the team or by the family members on a regular basis. That afternoon we evaluated yet another testament to the human resilience. A.W. accompanied by his father came to the spine ward to be evaluated. A.W. is a 16 year old male that had a severe form of scoliosis that was deemed inoperable. (See Figure 11) Despite his disfiguring spinal deformity he was still able to be physically active and keep up with his friends. His prognosis however is limited, with a small likely hood of survival into the 40s, and progressive deterioration due to lung and heart issues from compression in the chest cavity due to the spinal deformity. We plan to continuously monitor him.

Figure 11: Anterior, Lateral, and Posterior views, of patient A.W. The first case of the day was S.K., a bright 18 year old female that suffered from idiopathic scoliosis. Her curvature was corrected from T4-T11 with posterior rods and screws. When we first evaluated her, her main concern was I just want to be normal and dance. The team was touched by her simple request and were gratified to see how encouraged she was after the surgery. The surgery lasted 6 hours, and went smoothly. She was discharged from the orthopedic ward 5 days later without any complications and an excellent correction. (See figure 12)

Figure 12: Patient S.K. (L) pre-operative image, (M) Pre-operative X-ray, (R) post-operation image.

 The second surgery of the day was performed on patient K.N., the previously mentioned woman, who was in a motor vehicle accident that resulted in paraplegia. The surgery stabilized the fracture by placing rods from T9 to L1. This was successful in alleviating her pain. (See Figure 13).

Figure 13: Dr. Lieberman talking to patient K.N. about her surgery. Day 6 (August 1, 2009) Prior to the start of a long but successful surgery, the team completed their rounds of the patients recovering on the wards. All of the patients were doing well with no complications. On the spine ward one of the patients returned with the MRI scan we asked him to get. This patient, R.W., was a 6 year old male that was in a freak accident. According to the father he had fallen from a tree and has been unable to walk, feel his legs or control his bladder or bowel function since the fall. After our initial evaluation and review of his x-rays we were lost as to the cause of the paralysis as there was no evidence of a spine fracture. As such we sent him for the MRI scan. As we reviewed the MRI scan the remaining history was then described to us. Apparently R.W. had fallen directly on a board with a nail sticking out of it. It was clear on the MRI scan that the nail had punctured his spinal column and severed the spinal cord at the T8 level. (See Figure 14) There is no surgical procedure that will correct this truly unfortunate injury. We were all astonished and disappointed, but no where near as disheartened as his father. All the struggles of Ugandans were clearly evident on his fathers face when he was told we could not help him.

Figure 14: MRI showing nail track and photo of nail puncture site. The surgical case for the day was P.T., a 10 year old female with focal kyphosis (forward bend) of the thoracic spine. The surgical procedures included a pedicle subtraction osteotomy (PSO) at T11, segmental instrumentation (screws and rods) at T9 to L1 and posterior instrumentation from T10 to T12. The surgery went remarkably well despite the intimidation of having the Chief of Orthopaedics assisting us and one of the surgeons succumbing to a vicious bought of gastrointestinal distress 2 hours into the case. She was taken to the ICU following the surgery for close monitoring. Within a few days she was walking and her posture dramatically improved. (see Figure 15)

Figure 15: Patient P.T. (L) Pre-operative X-ray, (M) Post-operative X-ray, (R) Post-operative image

 Day 7 (August 2, 2009) Sunday was a day of rest with no surgeries scheduled. The team checked on the patients early in that morning, and all were well. As we rounded on the ward we were introduced to a new admission. C.E. was a 47 year old male farmer, with a large family, who was diagnosed and treated for oral cancer 3 years prior, and was also suffering from HIV. He presented with severe back pain and neurologic loss being unable to walk. His x-rays revealed cancer that spread to his spine. This created compression on his spinal cord, resulting in the pain and immobility. We had him scheduled for a decompression in the hopes of alleviating some of his pain and regaining some neurologic function. As we explained to him the issue and proposed surgery his biggest concern was as a peasant farmer how am I going to pay you for your services. He underwent his surgery with no complications. As we were leaving later that week he did regain some leg function and had some pain relief. (See figure 16)

Figure 16: Dr. Lieberman discussing the surgery with patient C.E. Day 8 (August 3, 2009) Some of our patients from earlier in the trip were ready to go home and were discharged today. They were very happy with the results of their surgery and were grateful for what the team was able to do for them. This was the planned day for A.N.s second stage surgery. This included posterior instrumentation from T4 to L3 for her 120 degree scoliosis. The surgery resulted in a significant correction. (See figure 17)

Figure 17: Patient A.N. (L) Pre-operative and (R) Post-operative (R) X-ray Later that day the team had a surprise visit from Patient S.N., a 15 year old female, which was operated on in April 2008 for scoliosis. She and her mother were so grateful to Drs Lieberman and St Clair. (See figure 18a and 18b)

Figure 18a: Patient S.N. (L) Pre-operative image, (M) Pre-operative X-ray, (R) and Post-operative image

Figure 18b: Lieberman, Patient S. N., St. Clair Day 9 (August 4, 2009) The day began with rounds at the ICU in the main hospital to check on A.N., who was recovering according to plan. Upon returning to the spine ward to get ready for surgery we saw two other new patients. Patient N.J. was a 35 year old female that was complaining of general lower back pain without pain traveling anywhere in the extremities. Her radiographs did not show anything suggesting surgery as a treatment option. She was told that an anti-inflammatory drug would be her best option along with physical therapy. The other patient we saw was J.S., a 6 year old male, who got into an accident two months ago while playing with friends. After that day he has been unable to walk or control his bowel and bladder. The recent revelation of a nail injury immediately came to mind, but how likely could we see that tragedy again? We instructed the family to transport the child into town for an MRI. Two surgical cases were performed on Day 9. The first case was a 7 year old boy, patient J.G. who had a congenital scoliosis with a 40 degree curvature. He underwent a fusion from T7 to T12. The surgery resulted in a very good correction for J.G. Even though still a child, J.G. was able to understand his diagnosis and what how his spine would be corrected. (See figure 19)

Figure 19: Pre-operative image of patient J.G. with a 40o scoliosis The following case was that of a 3 year old female, P.A., who was diagnosed with congenital kyphosis and scoliosis. She was the youngest patient the team operated on during this mission. She underwent a right T10 thoracotomy (access to the spine through the chest) and an anterior release of the T9/10, T10/T11 and T11/T12 levels. This was followed by a posterior in-situ fusion T8 to L1 (fusion with her own bone and no rods or screws) with the rib beginning used as a bone graft. The surgery went smoothly without any major issues. Due to her age and the complexity of the surgery, P.A. was brought to the ICU to be monitored closely for a few days. Unfortunately P.A. did develop a persistent fluid leak from her chest tube which nesecitated further treatment after we had left Uganda. Thankfully our colleagues are now experienced enough to handle these issues. (See figure 20)

Figure 20: Patient P.A. (L) Pre-operative image, (M) Pre-operative CT, (R) Postoperative in the ICU

 Day 10 (August 5, 2009) During the morning rounds the patients were seen in the ICU, Orthopaedic ward and Spine ward. Many were discharged home today. The incisions were clean, there were no signs of infection, and the pain, if any, was very minimal and manageable outside of the hospital. Up to today we were privileged to work with Dr Emanuel Munyarugyero (anaesthesia Mbarara) who by no stretch of the imagination is one of the best anaesthsiologists on the planet. Despite the limited resources his skill, patience and compassion provided for a sense of confidence and comfort for the patients and the team. Despite not having Emanuel today, we were still able to start out a single but albeit extensive case. The patient R.A. was a 12 year old male with spinal Tuberculosis which resulted in the development scoliosis. The surgery consisted of an anterior release at T10/11, T11/12 with a T11/12 osteotomy and reconstruction with rib. This was followed by a posterior approach for instrumentation and fusion from T8 to L1. Despite the extensive nature of his surgery R.A. recovered remarkably well in the ICU and within two days was sitting up, eating and even walking around. (See figure 21)

Figure 21: Patient R.A. (L) Post-operative X-ray, (R) Post-operative image

 That day patient J.S. and his parents returned the Spine ward with the MRI. The results of the study showed J.S. like many others had TB of the spine. The fall incident was purely coincidental and was not the ultimate cause of the paraplegia. He will require surgery and as the teams departure was imminent he would be operated on by the local spine team led by Dr Nyati. (See figure 22)

Figure 22: Patient J.S. (L) MRI with TB mass, (R) Patient in ward Day 11 (August 6, 2009) The team split up this morning to get the operating room set up and finish the ward rounds. The first case involved a 7 year old female, D.G., who had a congenital kyphosis. This type of spinal deformity renders the individual at high risk for paralysis with growth as the spinal cord is stretched over the growing hump. The surgery consisted of posterior instrumentation from the T9 to L1 spinal levels, to allow the spine to continue to grow from in front but tether the spine from behind. The surgery went well and she recovered without any incidents. (See Figure 23)

Figure 23: Patient D.G. (L) Pre-operative X-ray, (R) Post-op in Spine ward

 The last case the team tackled was patient C.E., the 47 year old male farmer who had oral cancer that spread to the spine. He underwent a tumor decompression at levels T12 and L4. Specimens were collected and sent to the pathology and microbiology department for analysis. (See figure 24)

Figure 24: Patient C.E. Pre-operative X-rays After the surgeries were done for the day, the team went to dinner with the faculty and administration from Mulago Hospital. This was a wonderful social event that certainly validated the purpose of the mission and further established the future vision. We all exchanged our thoughts and views regarding the need to provide care and education to those who treat spine pathology in Uganda. It was absolutely the crowning moment of the visit when the hospital chief administrator ensured that we would always be welcome. Day 12 (August 7, 2009) August 7th was our last day at Mulago. Dr. Lieberman gave a talk to the faculty and residents about the diagnosis and treatment of scoliosis. Following this informative session, we made our final round to see the remaining patients on the wards. To our gratification everyone was doing well. P.A. was still in the ICU. But the local team had a plan and would update us on her progress. Table 2 is a complete list of the surgical cases performed during this trip. It is clear that the severity of cases has intensified over the 4 years of visits. It is also clear that the local health professionals are now understanding the impact they can have on relieving pain and suffering due to spinal pathology. Simple things like trauma management and early antibiotics will alleviate so much grief. Every member of the team was impacted by what they experienced on this mission. It will forever have an impact on the way we, the team, think about life!

Epilogue
Dr Isador Lieberman; After four years of questioning, it is now clear that we are making a difference. This was by far the most productive and gratifying visit to Uganda. I am indebted to the team for their boundless devotion. I am enthused by the fact that others now want to join the effort. Uganda is not the only place that is in need. I encourage anyone with an interest to visit the Health Volunteers overseas website (www.HVOUSA.org) to find out more. Dr Mark Kayanja; It was with mixed emotion that I boarded the plane from Cleveland to Entebbe to embark on the July-August 2009 Spine Mission. A lot of changes had taken place since the inception of the Mission. One of the reasons that I left Uganda was the dissatisfaction with the state of Spine surgery. Now Spine surgery in Uganda is so much more different than at the inception of the Spine Mission from the concerted collective efforts of many individuals and teams. It was an opportunity to once again meet and work with colleagues with whom I had spent my earlier formative years in training and early practice. The feeling of once again working together to provide care for the needs of patients in Uganda was uplifting. However some things only change slowly, and from the experiences in North America the rude awakening to Spine surgery in Uganda was abrupt. Not so much a disappointment but a challenge, to make things better and to continue the commitment I made along time ago to try to make a difference. From the collective efforts, difficulties and challenges of the April-May Mission the July-August Mission was a great success. If only there was more time so much more could be done. The experience was exhilarating and life changing and I bonded with the team. The gratitude of the patients I was fortunate to participate in management of was priceless. As I travelled back to Cleveland after the mission, I realized that once again Uganda had that indelible mark on me, I will be back for more.

Dr Selvon St Clair;I returned to Uganda with much less trepidation compared to my first visit. This allowed me to immediately contribute and enjoy the many aspects of the mission. Although, the conditions at Mulago hospital remain rudimentary at best, there were definite improvement in both the working conditions and the management of the spine ward and operating room. I felt that our efforts along with other international orthopaedics missions are truly having an impact on the way orthopaedics, especially spine care is delivered. Of particular enjoyment to me this trip was the opportunity to closely interact with the orthopaedic residents. Teaching the junior residents to expose the spine and comanage the patients on the wards was extremely rewarding. Finally, unlike the last trip, I left Uganda with a sense of contentment knowing that our Ugandan colleagues were exceedingly enthusiastic to provide outstanding care to the many spine patients that we had the privilege to treat.

 Donna Sustar;To say I had reservations about the trip is an understatement. I was scared to the point of nausea, I have never traveled out of the country before and should of started with a simple trip to Detroit. After the initial shock of it all, I jumped in full speed ahead in classic Donna, take charge style. Then something happened to me, I fell in love. I fell in love with the people and the country and the pure act of giving and doing what I loved most helping the people who needed it the most. However, as much as I helped the people of Uganda, they helped me. I learned so much from my trip. I learned how strong the human spirit is, how much joy a piece of candy can bring, and about giving unselfishly. What I took away most from the trip is that my idealist ideas are not wrong, and I am glad I have not given them up like most people told me too. One person can make a huge life changing difference. Now I do LOVE Joint Commission (JHACO) and some of the western practices, but Uganda is under my skin, a part of my soul, and I can't wait to go back!

Brian Failla;After so many months of planning and anticipation, its hard to believe that this trip to Uganda is over! I had a mixture of emotions in the time leading up to our departure: pride at having been invited, the pressure of planning & anticipating every detail needed to operate many worlds away from the familiarity of home and certainly a reasonable amount of fear. My experiences there have changed me. When juxtaposed to the difficulties I witnessed in Uganda, I have a renewed appreciation for all the opportunities that we have available to us here in the United States. Things that we take for granted at home like clean water, healthy food, ready and comfortable transportation and even a soft bed are luxuries not available to the majority of the patients and families of patients that I met at Mulago Hospital. I was inspired and humbled by the selflessness of the surgical team. Their drive to not only do, but also teach so that others might do for themselves is amazing. And, although this was a monumental undertaking, it highlights for me how even small gestures can make profound differences to those in need. I am eternally grateful for this truly life-changing experience that I will carry with me for the rest of my life

Michael Silverstein;As a medical student, I spend a lot of time learning about the disparities in healthcare around the world. We see pictures, hear stories and even listen to talks from doctors that have made the trip overseas to contribute. Yet, nothing can equate to what you see and how you feel when you are actually there providing care. This trip has taught me many things about myself and it will always have an impact on me as a physician.

 Table 2: The surgical cases during the Uganda mission trip Initials Age Sex Diagnosis Surgical Procedure
P.A. 3 F Congenital kyphosis and scoliosis Right T10 thoracotomy, anterior T9/10, T10/11, T11/12 discectomy, posterior T8 to L1 in situ fusion augmented with rib graft Anterior T10/11 T11/12 release and reconstruction with rib graft (T9), T11/12 ostectomy; posterior T8 to L1 segmental instrument correction and fusion T12 and L4 laminectomy for tumor resection T9 to L1 Posterior Instrumental fusion Posterior T7 to T12 Instrument and fusion Posterior segmented T6 to L1 instrumentation and fusion T5 to T12 In situ correction and fusion Posterior right sided convex facet and lamina fusion T7 to T12 Bilateral L5/S1 laminectomy, nerve root exploration, decompression, discectomy Right T10 Thoracotomy, Anterior release and Posterior instrumentation at T12/L1 1) Anterior T6/7, T7/8, T8/9, T9/10, T10/11 2) T8, 9,10 Rib thoracoplasty, T4 to L3 segmental instrumental and fusion Right Hemilaminectomies at T7 to T11 and decompression T9/10/11/12/L1 Segmental Insitu and Fusion T9 to L1 segmental in situ fusion, T11 Pedicle Subtraction Osteotomy, T10 to T12 PLF

Complications
Chylothorax

A.R.

12

Post TB kyphosis

None

C.E. D.G. J.G. B.J. S.K. J.K.

47 7 7 15 18 7

M F M F F F

Central stenosis/ tumor Congenital Scoliosis/ kyphosis Congenital Scoliosis Idiopathic scoliosis Scoliosis Scoliosis

None None None None None None

G.M.

19

Spinal Stenosis

None

G.M.

60

Decompression Scoliosis (rigid 120o)

None

A.N.

17

None

S.N. K.N. P.T.

35 54 10

F F F

Epidural mass T10/11 Fracture dislocation Congenital Kyphosis

None None None

 Photo Highlights

Two children enjoying the sweets we gave out.

The slums of Uganda

A road side market

The team at work

Examining patients on the Spine Ward

The worlds best anaesthesiologist