• Getting ready to do the first Vim thalamotomy in Niger.

    Editor’s note: To view a selection of images from Dr. Spiegelmann’s journey to Niger, explore the multimedia presentation, “.”

    October 31, 2014

    There’s no radiation therapy machine in. Not even one for 17 million people. So if you have a glioma, you are done in a month, which you could say is not that wrong, considering the prognosis. But the same grim outlook applies to breast cancer, or to a benign base-of-skull meningioma.

    So it might be esoteric and misplaced to be doing a Vim thalamotomy to treat an old guy’s tremor, or for the same token, a stereotactic biopsy in a man with a couple of ugly-looking intra axial lesions surrounded by extensive edema. It could be metastases, or it could be one of the common central nervous system (CNS) infections seen here, such as toxoplasma (AIDS is endemic) or tuberculoma. The usual management is antibiotics and steroids. If the patient gets better, great. If not, in any case, there is not any definitive treatment that you could offer here. I ask Samuila, “What does a person in need of radiation therapy do?” “Well,” he answers, “if he has enough money, he can seek treatment in one of the nearby countries featuring radiotherapy. If not, he just dies.”

    Samuila Sanoussi is the only certified neurosurgeon in Niger. He was born in a small town 550 miles from Niamey, Niger’s capital, and the epicenter of the political and educational life in the country. Samuila got his neurosurgical training in , and remained there for an additional two years as a staff neurosurgeon.

    We are sitting at one of the few restaurants in , overlooking the city at night. Not that you can see much. There are very few lights in a sea of darkness. Niamey does not live by night. I ask Samuila how was it to come back to Niger after so many years in France. “It was very hard,” he concedes. But not for the reasons I would assume. There was no neurosurgical instrumentation here. No power drill. No suction. No bipolar coagulator, and of course, no operating microscope. But Samuila wanted to come back: “I could’ve remained in Strasbourg, but what was there for me? I wanted to make a difference; I wanted to be of relevance here, in the place where I belong.”

    And he has done it. He has a small but very motivated team of nurses and physician assistants, and they together make the most of the thin resources at hand at the .

    We are having dinner at this restaurant overlooking the city, the heat is still high, the steak feels right. But our good mood is only marginally related to those. We are exhilarated because we’ve accomplished something: one week of working together, two years after meeting in , at the first convention ever of the to be held in Africa, in November 2011. Samuila gave a talk describing neurosurgery in Niger. He mentioned that stereotactic surgery was nonexistent there, since he has no stereotactic equipment, no training in that field, and no outlook of getting resources for that purpose anytime in the foreseeable future.

    Spiegelmann and his host in Prof. Samouila’s office at the Hopital National.

    While listening to his talk, I thought of one of my frames (which I custom-built in the 1990s for my personal use), that had become just a display piece in my office, once I introduced computerized planning in my routine. For a few years, though, when stereotactic planning only required a ruler, a pencil and a school calculator, this was my favorite frame with which I performed a few hundred procedures.

    I looked for Samuila that evening at the cocktail party and told him that I had this frame in perfect condition, and I could not think of a better use for it than sending it to Niger. But of course he would need some training. And I said that I would be happy to come over and do it with him.

    Easier said than done. Getting the OK from to donate my frame was no problem. Delivering the frame to Niamey was something else. There are no diplomatic links between and Niger, no “interest desk,” nothing. It took me more than one year to find someone in the Foreign Affairs Ministry who agreed to take the stereotactic frame and deliver it “safely” to Africa. The itinerary was convoluted and included a relay in , where the Israeli Embassy made contact with one of Prof. Sanoussi’s relatives, who personally took the gadget to Niamey. But of course, there was nothing Samuila could do with it until I came (the CT-localizer cage, made out of plastic, I had decided I’d bring with me to assure it would arrive in one piece).

    And then both of us, busy clinicians, had to invest some time to get the needed authorizations (visa; letters from my hospital confirming that my old RF generator/stimulator is a piece of medical equipment and not a malicious gadget, so to improve the odds of not being stopped by airport security personnel; passive OK from the Foreign Ministry to visit Niger). We finally set dates. I tested again, and again the RF equipment and thermo couple electrodes that for many years were left to oblivion, confirmed they were in mint condition, packed and padded them the best I could in my carry-on, threw in some biopsy needles, and off I went.

    From the air, flying from the northeast, Niger is a vast desert. As the plane approaches Niamey, patches of greenery interrupt the seas of sand. Samuila is at the airport to welcome me. In the evening, we go through our schedule. Our first day is spent seeing patients who could be suitable for surgery and checking that all the parts we need (RF generator, frame, electrodes, needles) arrived in working condition. Samuila has made rounds in the hospital, telling colleagues I’ll be here this week, and that we’ll welcome patients with movement disorders. The pediatricians played along. In the morning, as we arrive in Prof. Sanoussi’s office, coming through the open spaces in-between the one-story pavilions of the Hopital National, dozens of mothers with sick small children on their backs await for us in the 105-degree-Fahrenheit heat. We begin seeing them in Samuila’s office. Almost all of them are affected with cerebral palsy, with diverse degrees of spasticity and limbs weakness. It is clear to us that the long queue outside does not bear candidates for stereotactic surgery, but we see them all anyway, even for a couple of minutes, because these desperate mothers have come, in some cases, from far away and they deserve at least to be seen and to be heard. As these children come and go, with their mothers who, in many cases, are left alone by their male partners to carry on with their lives and their handicapped offspring, I am overwhelmed by the nonsense we live. There’s no rehabilitation ward in this hospital, no pediatric neurologist in Niger, and, of course, no prosthetic aids. These children, crippled at birth frequently by perinatal infections, have absolutely no chance. Baclofen pumps, planned rehabilitation and orthopedic corrections are not going to happen here in the foreseeable future.

    Samouila poses in front of the scanner screen where a target localization procedure has been completed and is ready for printing.

    In the remaining days of my stay, we carry out four procedures — a Vim thalamotomy in a tremor-dominant PD patient and three biopsies for diverse lesions, each requiring some differences in planning. We need to make some improvisations to overcome pitfalls for which we could not plan ahead (such as the frame attachment to the operating table, or the CT couch). The CT scanner in the National Hospital is broken and will be replaced by a new one in the next few months, so that we take our framed patients on ambulance to a nearby clinic that has the only working CT scanner in Niamey. Needless to say, CT for stereotaxis is new to the whole team, so we spend a good deal of time with our first patient, achieving proper positioning, writing protocols for thin-slice, large-field scanning, and setting the tools for on-screen target and trajectory calculation, cut-film printing that will enable multi-slice planning for functional cases, and going through the intricacies of AC-PC determination, graphic reconstruction of ICL on paper diagrams, and determination of magnification factors. Here I should disclose that it took me a good deal of time before the trip to recall the procedural steps I used to make in hundreds of cases more than 15 years ago.

    The last morning in Niamey I give a talk on stereotactic applications to the hospital’s staff, and then Prof. Sanoussi performs the last biopsy we would be doing together. But he already knows the technique, and he is getting used to think in stereotactic terms of safe trajectory and its determination. More training will be needed for thalamotomies and pallidotomies. But this is OK, for it gives us a reason to plan our next time together.

    And when the sun goes down in a feast of colors past the Niger River, I think again on the meaning of treating tremor where spasticity is king, or getting pathological diagnoses that won’t be followed by tailored treatment. But this time, I know the answer. Neither Samuila nor myself are used to fitting what we do to the conditions at hand. Making a change, setting the clock, is what sets us in motion every day. And we are doing it. Here in Niger.

    Roberto Spiegelmann, MD, is head of the stereotactic radiosurgery unit in the department of neurosurgery at Chaim Sheba Medical Center, Tel Hashomer, Israel. A past president of the International Stereotactic Radiosurgery Society, Dr. Spiegelmann sits on the board of directors of the World Society for Stereotactic and Functional Neurosurgery. The author reported no conflicts for disclosure.



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    1. Great work! We have a couple of Patil frames we don’t use anymore which we could donate. Integration with CT very intuitive and focal point is at 21 cm so any biopsy needle that length or longer can be used.

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