Private healthcare sector spine surgery: patient and surgeon profiles from a large open medical scheme in South Africa.

Background It is generally understood that the profile of spine surgery varies by setting, based on factors such as the age profile of the population, the economic context and access to healthcare. Relatively little is known about the profile of spine surgery in South Africa, although one previous report from the public healthcare sector suggested a high burden of trauma and infection-related surgery. To our knowledge, there has been no formal investigation in the private sector. A holistic understanding of spine surgery within our setting may be beneficial for applications such as resource allocation and informing the training needs of future specialists.   Objectives To provide insight into spinal surgery in the South African private healthcare sector by describing spine surgery characteristics within a large open medical scheme, including both patient and surgeon profiles.   Methods This retrospective review included adult inpatient spine surgeries funded by the largest open medical scheme in South Africa between 2008 and 2017. An anonymized dataset extracted from the scheme records included patient demographics, ICD-10 codes, procedure codes and surgeon specialization. Descriptive patient and surgery data were presented. Furthermore, the association between patient and surgery factors and surgeon specialization was investigated using univariate and multivariate analyses.   Results A total of 49,576 index spine surgeries were included. The largest proportion of surgeries involved members 40-59 years old (n=23,543, 48%), approximately half involved female members (n=25,293, 51%) and most were performed by neurosurgeons (n=35,439, 72%). At least 37,755 (76%) surgeries were for degenerative pathology, 2,100 (4%) for trauma and 242 (0.5%) for infection. Adjusted risk ratios (aRR) significantly associated with orthopaedic surgeon specialization included cervical spine region aRR = 0.49 (95% C.I. 0.39-0.61), trauma aRR = 1.50 (95% C.I. 1.20-1.88), deformity aRR = 1.77 (95% C.I. 1.33-2.35) and blood transfusion aRR = 1.46 (95% C.I. 1.12-1.91).   Conclusion Spine surgery in South Africa's largest open medical scheme was dominated by surgery for degenerative pathology in older adults and was performed largely by neurosurgeons. This constituted a stark contrast to a previous report from the public sector and highlighted a mismatch between exposure during public sector registrar training and private practice post-specialization. The findings support the need for private-public collaboration as well as the importance of spine fellowships for all specialists intending to practice spine surgery.

Incidence of spine surgery in the South African private healthcare sector: ten-year trends within a large open medical scheme.

PURPOSE: Studies from developed countries suggest a dramatic increase in the utilization of spine surgery in recent decades, however less is known about spine surgery rates in the developing world. The aim of this study was to investigate ten-year trends in the incidence of spine surgery within South Africa's largest open medical scheme. METHODS: This retrospective review included adult inpatient spine surgeries funded by the scheme between 2008 and 2017. The incidence of spine surgery was investigated by age group-overall and for degenerative pathologies, fusion and instrumentation. Surgeons per 100,000 members were determined. Trends were evaluated by linear regression and by crude 10-year change in incidence. RESULTS: A total of 49,575 spine surgeries were included. The incidence of surgery for lumbar degenerative pathology showed a significant upward trend among 60-79 year olds but declined among 40-59 year olds. The incidence of lumbar fusion and lumbar instrumentation declined significantly among 40-59 year olds with little change among 60-79 year olds. The ratio of orthopaedic spinal surgeons decreased from 10.2 to 6.3 per 100,000 members whereas the ratio of neurosurgeons decreased from 7.6 to 6.5 per 100,000. CONCLUSION: Spine surgery in the South African private healthcare sector bears some similarity to developed countries in that it is dominated by elective procedures for degenerative pathology. However, the findings did not reflect the marked increases in the utilization of spine surgery reported elsewhere. It is hypothesized that this may be partly related to differences in the supply of spinal surgery.

Viewership footprint for a low-resource, student-centred collaborative video platform to teach orthopaedics in southern Africa.

BACKGROUND: Institutions are increasingly using technology to augment the class learning experience of medical students. Especially in Africa, local content is key to allow insights and knowledge to emerge and build transformative capacity for students and patients. There is currently no peer-reviewed video content produced by students with the aim of providing education on orthopaedic topics for medical students and patients in this region. OBJECTIVES: To evaluate the demographic and geographical viewership as well as video-specific statistics of orthopaedic teaching videos for medical students on a YouTube channel, with the expressed aim of informing future content production. METHODS: Videos were produced by South African (SA) medical students as a problem-based collaborative project. Student-owned smartphones and various types of free video editing software were used to produce these videos, which were then assessed by a group of orthopaedic specialists and uploaded onto a YouTube channel (UCTeach). The analytical reports of this channel generated by Google and YouTube were analysed regarding watch time per day (minutes), average view duration (minutes), most watched videos, top geographies, age and gender. RESULTS: A total of 83 videos were uploaded to the UCTeach Ortho channel during a 2-year period, with a total watch time of 857 062 minutes and 337 983 views. The majority of viewers were between the ages of 18 and 34 years (85%). India had the most views (n=69 089), followed by the USA (n=66 257) and SA (n=21 882). Most of the videos were watched on mobile phones (n=183 299) and computers (n=128 228). The most watched video, produced in April 2016, was on physiological and pathological gait, with 51 314 views. CONCLUSIONS: Our study provides proof of concept for a new educational material creation and dissemination strategy. A low-cost local collaborative orthopaedic video project by medical students for medical students can lead to high view counts and watch time on YouTube. It is accessible to audiences in low-, middle- and high-income countries. The students' educational videos also reached a global audience consistently over a 3-year period.

Impact of HIV on spontaneous spondylodiscitis.

AIMS: HIV predisposes patients to opportunistic infections. However, with the establishment of Highly Active Anti-Retroviral Therapy (HAART), patients' CD4 counts are maintained, as is a near normal life expectancy. This study aimed to establish the impact of HIV on the bacteriology of spondylodiscitis in a region in which tuberculosis (TB) is endemic, and to identify factors that might distinguish between them. PATIENTS AND METHODS: Between January 2014 and December 2015, 63 consecutive cases of spontaneous spondylodiscitis were identified from a single-centre, prospectively maintained database. Demographics, presenting symptoms, blood results, HIV status, bacteriology, imaging, and procedure undertaken were reviewed and comparisons made of TB, non-TB, and HIV groups. There were 63 patients (22 male, 41 female) with a mean age of 42.0 years (11 to 78; sd 15.0). RESULTS: In total, 53 patients had tuberculous, nine bacterial, and one cryptococcal spondylodiscitis. There were 29 HIV-positive patients, 29 HIV-negative patients, and five patients with unknown HIV status. The local incidence of TB spondylodiscitis was 1.54/100 000 and that of non-TB spondylodiscitis was 0.29/100 000 per annum. TB patients were younger with similar clinical presentation and infective markers, but were more likely to have a paraspinal abscess. They were also less likely to have a hyperintense disc on MRI. There was no difference between the two HIV groups. CONCLUSION: In areas of endemic TB and HIV, TB remains the most common cause of spondylodiscitis at five times the rate of non-tuberculous causes. HIV managed with HAART increases the rate of infection but does not influence the bacteriology unless there is a low CD4. There was little to differentiate the groups. TB /HIV co-infected patients were younger than non-TB and HIV-negative patients. Non-TB patients were more likely to have disc hyperintensity on MRI and TB patients were more likely to have abscess formation, but as both groups exhibited these features, neither was diagnostic. Culture confirmation remains necessary. Cite this article: Bone Joint J 2019;101-B:617-620.

Child and adult spinal tuberculosis at tertiary hospitals in the Western Cape, South Africa: 4-year burden and trend.

The aim of this retrospective review was to assess the overall burden and trend in spinal tuberculosis (TB) at tertiary hospitals in the Western Cape Province of South Africa. All spinal TB cases seen at the province's three tertiary hospitals between 2012 and 2015 were identified and clinical records of each case assessed. Cases were subsequently classified as bacteriologically confirmed or clinically diagnosed and reported with accompanying clinical and demographic information. Odds ratios (OR) for severe spinal disease and corrective surgery in child vs. adult cases were calculated. A total of 393 cases were identified (319 adults, 74 children), of which 283 (72%) were bacteriologically confirmed. Adult cases decreased year-on-year (P = 0.04), however there was no clear trend in child cases. Kyphosis was present in 60/74 (81%) children and 243/315 (77%) adults with available imaging. Corrective spinal surgery was performed in 35/74 (47%) children and 80/319 (25%) adults (OR 2.7, 95% confidence interval 1.6-4.5, P = 0.0003). These findings suggest that Western Cape tertiary hospitals have experienced a substantial burden of spinal TB cases in recent years with a high proportion of severe presentation, particularly among children. Spinal TB remains a public health concern with increased vigilance required for earlier diagnosis, especially of child cases.

Spinal tuberculosis: review of current management.

Tuberculosis (TB) remains endemic in many parts of the developing world and is increasingly seen in the developed world due to migration. A total of 1.3 million people die annually from the disease. Spinal TB is the most common musculoskeletal manifestation, affecting about 1 to 2% of all cases of TB. The coexistence of HIV, which is endemic in some regions, adds to the burden and the complexity of management. This review discusses the epidemiology, clinical presentation, diagnosis, impact of HIV and both the medical and surgical options in the management of spinal TB. Cite this article: Bone Joint J 2018;100-B:425-31.

Hip and knee arthroplasty waiting list - how accurate and fair?

BACKGROUND: Resource-intensive procedures require the use of patient waiting lists in an attempt to increase fairness of access to surgery and improve surgical efficiency. Total hip and knee arthroplasty has waiting lists in excess of years. OBJECTIVES: To analyse our tertiary state institution's hip and knee arthroplasty waiting list to assess its accuracy. METHODS: At Groote Schuur Hospital, our hospital-maintained database was compared with the surgeons' personally maintained database. Patients were then telephoned to confirm their contactability, and to discover whether they still wanted the procedure, or if they had already had it. Waiting duration and patient demographics were then calculated. RESULTS: Of the 655 patients on the hospital waiting list, only 454 were contactable. Three hundred and nine patients still wanted the surgery, 93 had already undergone surgery and 52 no longer wanted surgery. The last group was the oldest and had had the longest waiting time. Those still waiting had waited 451 days (minimum - maximum (standard deviation), 90 - 1 593 (228.5)), those that had had surgery 371 days (0 - 1 728 (296)) and those no longer interested 523 days (138 - 1 881 (260.9)). A total of 429 patients were present on the surgeons' list but not on the hospital list. They had had longer waiting times than those on the hospital list. CONCLUSION: The arthroplasty waiting list is inaccurate due to the existence of two concurrent lists and poor data management, particularly of current contact details. The unfairness of a wide range of waiting times was identified, with patients only on the surgeons' personal database disadvantaged. These deficiencies have prompted the introduction of  a scoring-based prioritisation system incorporating clinical, radiographic and societal parameters, in an effort to improve fair and appropriate access to this high-cost care.

Kyphectomy in Children With Severe Myelomeningocele-Related Kyphosis.

STUDY DESIGN: Retrospective review of prospectively maintained database. OBJECTIVES: To review myelomeningocele patients with severe kyphosis undergoing kyphectomy surgery in terms of complications and clinical and radiographic outcomes. SUMMARY OF BACKGROUND DATA: Because of posterior element abnormality in myelomeningocele, the extensor muscles act as perverted flexors, driving progressive kyphosis that resulted in sitting, respiratory, and skin breakdown problems. METHODS: Clinical case notes and x-rays of seven myelomeningocele patients undergoing kyphectomy surgery were reviewed with a minimum follow-up of 24 months. They consisted of four males and three females with an average age of 9.5 years at surgery. Surgery was performed in three despite open pressure ulcers that failed to heal. These wounds were all closed primarily at initial operation, and no flaps were required. Pedicle screw and sublaminar wire constructs were utilized with iliac screws for distal control. RESULTS: The median surgical time was 245 minutes (165-285), with an estimated blood loss of 700 mL (500-2,550). The preoperative kyphosis of 142 degrees (90-180) was corrected to 15 degrees (5-45) representing a 92% correction. All experienced improved sitting. There were no early complications but 2 patients with preoperative pressure ulcers returned at 13 months with recurrent sepsis and wound breakdown. Their osteotomy had fused, and the infection settled after instrumentation removal and antibiotic administration. CONCLUSION: Although an infrequent presentation today, severe kyphosis in myelomeningocele patients causes not only a major functional impairment but threat to their life with apical pressure sores. Kyphectomy and posterior instrumented spinal fusion can be performed safely, even in the face of an open sore with excellent kyphotic correction and resultant improved functionality and ability to sit. These open sores can be closed primarily without the requirement of plastic surgery as a result of the shortening and extension of the spine.

Tracheostomy, ventilation and anterior cervical surgery: Timing and Complications.

BACKGROUND: Cervical spine injured patients often require prolonged ventilatory support due to intercostal paralysis and recurrent chest infections. This may necessitate tracheotomy. Concern exists around increased complications when anterior cervical spine surgery and tracheotomies are performed. OBJECTIVE: The primary aim of this study was to evaluate the effect of tracheostomy in anterior cervical surgery patients in term of complications. In addition, the aetiology of trauma and incidence of anterior surgery and ventilation in this patient group was assessed. METHOD: Patients undergoing anterior cervical surgery and requiring ventilation were identified from the unit's prospectively maintained database. These patients were further sub-divided into whether they had a tracheotomy or not. The aetiology of injury and incidence of complications were noted both from the database and a case note review. RESULTS: Of the 1829 admissions over an 8.5 year period, 444 underwent anterior cervical surgery. Of the 112 that required ventilation, 72 underwent tracheotomy. Motor vehicle accidents, followed by falls, were the most frequent cause of injury. There was a bimodal incidence of tracheostomy insertion, the day of spine surgery and 6-8 days later. There was no difference in the general complication rate between the two groups. With regards to specific complications attributable to the surgical approach/tracheotomy, there was no statistically significant difference. The timing of the tracheotomy also had no effect on complication rate. Although the complications occurred mostly in the formal insertion group as opposed to the percutaneous insertion group, this was most likely due to selection bias. CONCLUSION: Anterior cervical surgery and subsequent tracheostomy are safe despite the intuitive concerns. Timing does not affect the incidence of complications and there is no reason to delay the insertion of the tracheostomy. Ventilation in general is associated with increased complications rather than the tracheostomy tube per se.

GeneXpert polymerase chain reaction for spinal tuberculosis: an accurate and rapid diagnostic test.

The lack of an accurate, rapid diagnostic test for mycobacterium tuberculosis (TB) is a major handicap in the management of spinal TB. GeneXpert, a new, rapid molecular diagnostic test is recommended as the first line investigation for suspected pulmonary TB in areas with a high prevalence of HIV or drug resistance, yet it has not been validated for the diagnosis of musculoskeletal TB. The aim of this study was to assess the accuracy of GeneXpert in diagnosing spinal TB. A prospective clinical study of 69 consecutive adults with suspected spinal TB was conducted at a tertiary hospital in an area with the highest incidence and prevalence of TB in the world. GeneXpert was used on tissue samples of the enrolled patients and its diagnostic accuracy compared with a reference standard of tissue in liquid culture. A total of 71 spine samples from 69 patients (two re-biopsies) were included in the study. The GeneXpert test showed a sensitivity of 95.6% and specificity of 96.2% for spinal TB. The results of the GeneXpert test were available within 48 hours compared with a median of 35 days (IQR 15 to 43) for cultures. All cases of multi-drug resistant TB (MDR TB) were diagnosed accurately with the GeneXpert test. The MDR TB rate was 5.8%.

Shallow-water spinal injuries--devastating but preventable.

BACKGROUND: Shallow-water diving injuries have devastating consequences for patients and their families, requiring intensive use of resources in both the acute and rehabilitative phases of injury. With the final clinical outcome often poor, the question is raised as to whether a target group can be identified for whom to implement a preventive programme. OBJECTIVE: To evaluate the demographics, clinical features and outcomes of shallow-water diving injuries in an acute spinal cord injury (ASCI) unit. MATERIALS AND METHODS: All patients admitted to the ASCI unit with diving-related injuries were entered into the study. Data regarding demographics, injury profile and subsequent management were collated. All case notes and X-rays were reviewed. Ethical approval was obtained. RESULTS: Forty-six patients were reviewed from 19 April 2003 to 8 February 2009. A steady annual increase in diving injuries was noted. A very specific patient profile was identified: 91% male incidence, average age 23 years, 37% admitted alcohol use, with a summer-time prevalence. Compression-flexion type injuries were most prevalent, with an orthopaedic level of C5 and neurological level of C4 being the most common injury sites. A third of diving injuries occurred in the sea, 20% in swimming pools, 20% in rivers, 11% in tidal pools and 4% in dams. CONCLUSION: A very specific patient profile was identified, and the severity of shallow-water diving injuries was confirmed. No current preventive programme exists except for a single television advertisement. These data will be used to motivate further educational and preventive programmes for reducing the incidence of diving-related injuries.

Cervical spine injury outcome--a review of 101 cases treated in a tertiary referral unit.

UNLABELLED: Cervical spinal cord injury (SCI) is a devastating event for the patient and family. It has a huge impact on society because of the intensive resources required to manage the patient in both the acute and rehabilitation phases. Given the resource-limited setting in South Africa, questions are often raised regarding whether the outcome of this group of patients justifies the expense of their care. However local data have not been available to date. OBJECTIVE: To evaluate the mortality, morbidity and functional outcome of cervical SCI patients in the South African environment. MATERIAL AND METHODS: All cervical SCI patients managed in the acute spinal cord injury unit at Groote Schuur Hospital over a 12-month period were included. Epidemiological data, management, complications, neurological status and change were assessed. Those referred for rehabilitation were followed up in terms of mortality and ambulation status. RESULTS: There were 101 patients, with an average age of 34.7 years. Motor vehicle accidents were the commonest cause of injury, with violence contributing 21%. Fifty-nine patients required referral to a rehabilitation unit. Of these, 18 were functional walkers, and only 6 were care-dependent. By 1 year post injury all but 1 patient had been discharged from the health service. Fourteen patients died; in half of these cases injury was at C5 level and above. CONCLUSION: Despite cervical SCI being a devastating event, aggressive early intervention yields a better-than-expected 1-year survival rate. Associated problems, such as pressure sores, remain a major problem both for the patient and in terms of health care costs. It is difficult to predict prognosis on presentation because of spinal shock. It is recommended that all patients initially be treated aggressively, with exit strategies in place once all the information is available and a confident assessment of poor prognosis can be made.

Gunshot injuries of the spine - a review of 49 cases managed at the Groote Schuur Acute Spinal Cord Injury Unit : trauma

The Acute Spinal Injury Unit; relocated from Conradie Hospital to Groote Schuur Hospital in mid-2003; admitted 162 patients in the first year of its existence. A large number of these injuries were the result of interpersonal violence; particularly gunshot wounds. Aim. To review patients with gunshot injuries to the spine; with reference to neurological injury; associated injuries; need for surgery and complications. Methods. A comprehensive database is maintained to collect data on all spinal injury admissions. These data; as well as case notes and X-rays; were reviewed for all gunshot spine patients admitted to the Acute Spinal Injury Unit over a year. Forty-nine patients were identified. Thirty-eight were male and 11 female with an average age of 27.5 years (range 15 - 51 + 8.53). The average stay in the acute unit was 30 (4 - 109 + 28) days. Results. The spinal injury was complete in 38 and incomplete in 8; with 3 having no neurological deficit. The level was cervical in 13; thoracic in 24 and lumbar in 12. Only 9 patients improved neurologically. The spine was considered stable in 43 cases. Stabilisation was performed in the 6 unstable cases. The bullets were removed in 11 cases as they were in the canal. There were 55 significant associated injuries; viz. 14 haemo-pneumothoraces; 16 abdominal visceral injuries; 3 vascular injuries; 4 injuries of the brachial plexus and 3 of the oesophagus; 2 tracheal injuries; 1 soft palate injury and 11 non-spinal fractures. Complications included 3 deaths and discitis in 3 cases; pneumonia in 6 and pressure sores in 6. Conclusion. Gunshot injuries of the spine are a prevalent and resource-intensive cause of paralysis. There is a high incidence of permanent severe neurological deficit; but usually the spine remains mechanically stable. Most of the management revolves around the associated injuries and consequences of the neurological deficit

Gunshot injuries of the spine--a review of 49 cases managed at the Groote Schuur Acute Spinal Cord Injury Unit.

UNLABELLED: The Acute Spinal Injury Unit, relocated from Conradie Hospital to Groote Schuur Hospital in mid-2003, admitted 162 patients in the first year of its existence. A large number of these injuries were the result of interpersonal violence, particularly gunshot wounds. AIM: To review patients with gunshot injuries to the spine, with reference to neurological injury, associated injuries, need for surgery and complications. METHODS: A comprehensive database is maintained to collect data on all spinal injury admissions. These data, as well as case notes and X-rays, were reviewed for all gunshot spine patients admitted to the Acute Spinal Injury Unit over a year. Forty-nine patients were identified. Thirty-eight were male and 11 female with an average age of 27.5 years (range 15-51 +/- 8.53). The average stay in the acute unit was 30 (4-109 +/- 28) days. RESULTS: The spinal injury was complete in 38 and incomplete in 8, with 3 having no neurological deficit. The level was cervical in 13, thoracic in 24 and lumbar in 12. Only 9 patients improved neurologically. The spine was considered stable in 43 cases. Stabilisation was performed in the 6 unstable cases. The bullets were removed in 11 cases as they were in the canal. There were 55 significant associated injuries, viz. 14 haemo-pneumothoraces, 16 abdominal visceral injuries, 3 vascular injuries, 4 injuries of the brachial plexus and 3 of the oesophagus, 2 tracheal injuries, 1 soft palate injury and 11 non-spinal fractures. Complications included 3 deaths and discitis in 3 cases, pneumonia in 6 and pressure sores in 6. CONCLUSION: Gunshot injuries of the spine are a prevalent and resource-intensive cause of paralysis. There is a high incidence of permanent severe neurological deficit, but usually the spine remains mechanically stable. Most of the management revolves around the associated injuries and consequences of the neurological deficit.