What is like to be the only dedicated spine surgeon in a country of more than 2 million inhabitants? Alexander van der Horst, spine surgeon in Windhoek, Namibia, tells his story.

 

Why did you choose to do spine surgery and where did you do your training?

The spine is an ever-changing and exciting field of surgery. One needs to combine a good history and clinical examination with fine motor skills in the operating theater and be able to handle very stressful episodes during surgery.

I completed my training as an orthopedic surgeon at the University of Cape Town in South Africa and a one-year AOSpine Fellowship in a high-volume spine center under the guidance of Professor Robert Dunn at the Groote Schuur Hospital in Cape Town.

 

How do you make sure that you stay up-to-date?

I attend congresses and workshops and read the latest journals. I also organize trauma/spine training courses all over Namibia and am regularly invited as an AOSpine faculty member across Southern Africa. In the last few years, I have also been invited to Europe as a guest speaker. All of these activities force me to read and stay up-to-date.

 

Who has inspired and mentored you?

The field of spinal surgery inspires me. What I know about spinal surgery was initially taught to me by Professor Dunn during my AOSpine Fellowship. We were trained to be safe and “evidence-based,” conservative spinal surgeons. During my fellowship, I was exposed to various other mentors from neurosurgical and orthopedic backgrounds. Our weekly academic meetings included spine surgeons from the neighboring University of Stellenbosch. All of this contributed to a balanced approach to spine pathology.

 

Can you share a bit about spine surgery in Namibia?

I moved to Namibia in 2013, to take on the post of Senior Lecturer at the new Medical School at the University of Namibia. With this, I started "Before 2013, the Namibian government had a neurosurgeon visit from South Africa every three months."the Division of Orthopedic Surgery and wrote the fourth-year student curriculum. I also initiated a referral system and regular spine service for the government hospitals in Namibia. This is functioning smoothly, where 35-50 patients are seen weekly at an outpatient clinic, and we have a full theatre list each week.

 

Sweden contributed a spinal rehabilitation clinic, Spinalis Unit, to our hospital in 2013. On this front, I am also actively involved in academic ward rounds and teaching. I also run a limited private spine practice in Windhoek. For the last three years, the Head of the Department of Neurosurgery at Stellenbosch University, Professor AJ Vlok, who is also a fellowship-trained spinal surgeon, has offered an outreach service to Namibia to address more complex cranial pathology, and to train local doctors and students in neurosurgery.

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Please describe your typical working day?

Most days, I move between the government and state hospitals for X-ray meetings or ward rounds. I then meet students for a quick tutorial and prepare a lecture in my office. After lunch, I might go to my private practice for surgery or consultations. Emergency spine cases I tend to do at night or on weekends, as my week is always very full.

 

What are your most frequent operations?

On a weekly basis, I see spinal trauma due to our high motor vehicle accident rate. Trauma fixation of the spine is the procedure I perform most. In my private practice, the scope of work I perform is similar to Europe (cervical and lumbar degenerative surgery). In the government hospital, I tend to deal with spinal infections due to tuberculosis and tumors of the spine and spinal cord.

 

How did you get involved in teaching spine surgery?

I love to teach. Ironically, I was a terrible student and became bored quickly, so I try to be enthusiastic, to make the topic appealing so that "In my private practice, the scope of work I perform is similar to Europe. In the government hospital, I tend to deal with spinal infections due to tuberculosis and tumors of the spine and spinal cord."it is remembered. Because I am the only dedicated spine surgeon in Namibia, the onus is on me to teach at the local level. I have been asked to teach all over Southern Africa, and I visit 2-3 neighboring countries each year to teach as part of a team on spinal surgery. Naturally, being employed by the university also enables me to be involved spine and orthopedic teaching.

 

How does spine surgery in Namibia compare to the rest of Africa?

I have some experience in the neighboring African countries, and they are similar to Namibia in that the capitals generally provide good to excellent spinal care, but as soon as you move a few kilometers away from the capital, there is almost no spinal care.

It is my experience over the last four years that "I am on call 24/7, and there is no one to discuss a severe case or difficult MRI scan with quickly."the countries that have a dedicated, fellowship-trained spinal surgeon have been able to change the course of spinal surgery in that country.

 

What are the toughest challenges in your job?

Working in the government/state sector with all of its challenges and the massive workload is tough. Another challenge is not having an equally qualified surgeon to work with in the government hospitals.

 

What are the differences between private practice and public health care in Namibia?

There are two opposite poles in Namibia, which is similar to South Africa. In the private sector, those that have insurance or can afford the care have access to the latest in spinal care. The "The lack of equipment and facilities, including a theatre bed for spine surgery, good lighting, microscopes, and high-care beds for the post-operative period is a huge challenge."private sector is very well funded, has European class equipment, but serves the minority.

The opposite pole is the government hospitals. They are on a very tight budget, the facilities are old, and the theatres are often dilapidated. The theatre beds don’t function properly, there is inadequate lighting, the air conditioning does not work at times, and there is a limited and unpredictable supply of spinal implants to perform complex spinal surgery.

 

What do you consider the most significant challenges for spine surgeons in Southern Africa in general?

The lack of equipment and facilities, including a theatre bed for spine surgery, good lighting, microscopes, and high-care beds for the post-operative period is a huge challenge. The price of spinal implants also makes good spine care very difficult in a resource-limited country.

 

Where do you see the biggest opportunities for spine surgeons in Namibia, and Southern Africa in general?

I believe that dedicated, “fellowship trained” spine surgeons are the way to go to provide a relatively high level of care. Once established, these individuals can help to motivate an "I believe that dedicated, “fellowship trained” spine surgeons are the way to go to provide a relatively high level of care. "upgrade of the facilities to meet the needs of the population. Unfortunately, the standard spinal training that residents receive in South Africa in neuro and orthopedic surgery is not sufficient to deal with the scope of spine pathology that one sees these days, so a fellowship is of utmost importance, especially in our new medico-legal climate of litigation. Pathology wise, dealing with the massive load of tuberculosis of the spine, spinal tumors, and scoliosis is the biggest burden for spine care in Africa.

 

What advice would you give to a young surgeon in your region?

Complete your orthopedic or neurosurgery training and apply for a minimum one-year, accredited spinal fellowship at a high-volume center with hands-on experience. Accept nothing less! You will come face-to-face with the rigors and realities of working in a high demand center as a young doctor. This experience can be found in most of Southern Africa, where good and experienced hands are needed.

 

What does being a member of AOSpine mean to you, and how has AOSpine influenced your career?

It is probably the best forum to interact with other spinal surgeons around the world. The teaching offered on e-formats is extremely helpful, and the training courses are numerous across the globe. It is a truly global community of like-minded surgeons.

 

 

 

Alexander van der Horst BSc, BMedSc (Hons), MB, ChB is a South African-German Consultant Spine and Orthopaedic Surgeon based at the Central/Katutura Hospital Complex in Windhoek, Namibia.

 

For visiting opportunities or short term fellowship/observerships please e-mail me at gospine.avdh@gmail.com.