The Cape Town Stereotactic pointer clinical development and Applications

This dissertation describes the development and clinical use of a novel stereotactic neurosurgical system, the Cape Town Stereotactic Pointer (CTSP). This system has four main components; a halo containing three fiducials also serves as the platform for a tripod pointing device which is set with the aid of a 3D phantom or a printed setting diagram, and software which enables transformation of imaging space into patient space. Laboratory tests indicated an application accuracy of 1.9 +/- 0.6mm using the 3D phantom to set the tripod. From the first clinical application, the system underwent a series of iterations which could broadly be divided into four successive phases of refinement. This took place over a six year period, encompassing one hundred patients who underwent 115 stereotactic procedures. Indications for surgery included biopsy (62.6%), aspiration (15.7%) and cannulation (21.7%) and the surgical objective was realized in 101/109 cases (92.7%). Given the fact that six of the eight failures represented errors of surgical judgment that could not be ascribed to the device, and each of two system errors resulted in a significant modification to the system, the CTSP demonstrated a satisfactory level of accuracy in the clinical setting. This was accomplished at an acceptable complication rate, with one death five days after surgery attributable to a stereotactic procedure (mortality 0.9%) and major morbidity in two cases (1.7%); thirteen patients experienced minor complications, all of which proved to be transient (11.3%). A simple protocol for use of the CTSP evolved over the course of this study, making it easier for neurosurgeons from varying backgrounds to introduce stereotaxis into their practice with the help of this system. In addition to satisfactory levels of clinical reliability and safety, the system was versatile and also well tolerated by patients. It is hoped that the CTSP provides a costeffective alternative for neurosurgeons working in under-resourced settings. Sixty units of the production version of the CTSP have been sold and the system is now in use in ten countries

Surgical management of spasticity

The management of patients with cerebral palsy and other causes of spasticity is a challenge to an entire rehabilitation team and to caregivers. In South Africa,  neurosurgeons have had limited involvement in this field owing to a perceived lack of options, leaving the care of these patients largely in the hands of paediatric  neurologists and orthopaedic surgeons. A committed team-based approach, where a neurosurgeon is part of the decision-making process, can however significantly improve functional outcomes in patients with spasticity. Key to the evaluation and therapeutic decision-making is the focus on function – not only the range of  movement or the presence of spasticity. Some techniques can completely remove spasticity and contractures, but these mostly leave a patient with more functional impairment than they had before the surgery. With the careful combination of botulinum toxin injections and oral baclofen, these patients, who may benefit from further orthopaedic and neurosurgical procedures, can be identified and helped in reducing the function-limiting spasticity. With the emphasis on function as an individualising factor, significant improvements may follow minor interventions, e.g. performing a surgical procedure to allow reduced hip adductor spasticity, thereby allowing improved hygiene and less pain in a child in whom it was previously not possible to abduct the hips enough to change a nappy. Functional improvement does not necessarily equate to walking. We describe the process of evaluating patients with spasticity and outline the surgical decision-making process that helps towards an individualised therapeutic strategy in managing this challenging group of  patients

Charles F M Saint – South Africa’s original surgical pioneer

Charles F M Saint, a 33-year-old graduate from the University of Durham, Newcastle upon Tyne, was appointed to establish the first department of surgery in South Africa (SA) at the University of Cape Town (UCT) in 1920. A mentee of the celebrated British surgeon, Prof. James Rutherford Morison, Saint’s distinguished surgical pedigree and exceptional academic and clinical achievements underpinned his astute leadership and legendary ability to inspire, essential qualities necessary for the founding professor of SA surgery. Saint’s imprimatur gave primacy to teaching and a priority to skilled, rigorous and fundamental undergraduate instruction, expounding the Morison-Saint philosophy, which made the department the seedbed of SA surgery. He was the first to introduce basic research programmes in clinical departments. During his tenure, Saint received wide international recognition and honours and when he retired in 1946, he had taught more than 1 300 students, trained 7 professors of surgery and over 40 specialist surgeons, instilling his distinctive brand of disciplined, caring surgery. In his 26 years at UCT and Groote Schur Hospital, Saint laid the foundations and built a department of surgery with a global reach and an enduring legacy at the southern tip of Africa

Surgical management of epilepsy

The fact that epilepsy can be cured or ameliorated with surgery is an often neglected and overlooked aspect of modern management. Epilepsy affects almost 50 million people worldwide. One-third of people who suffer from epilepsy are refractory to  medication alone. It is this group of patients who may benefit from epilepsy surgery, which can be divided into three main categories, i.e. resection procedures, disconnection procedures, and neuromodulation procedures. The goal of surgery in epilepsy is to remove the epileptogenic region from the brain, or to disconnect it and thereby prevent spread to other parts of the brain. In cases where this is not possible owing to the location of the epileptic focus, certain neuromodulation techniques may benefit the patient. Successful outcomes of epilepsy surgery techniques vary from 50% to 80% in rendering patients free of their epilepsy; many more patients can expect improvement in the severity or frequency of their disabling seizures. The outcome depends on factors such as age, location of the epileptogenic zone, histology and cause of the seizures. Patients undergo a detailed and prolonged work-up to determine candidacy and to decide on the safest technique that will lead to the best outcomes. An experienced team should perform the surgery. This team should consist of multiple members who can attend to the medical, social,  psychological and reintegration needs of the patient before and after surgery

A Study of Compositional Techniques Used in the Fusion of Art Music with Jazz and Popular Music

An analysis of the author’s composition portfolio is presented with reference to selected compositions by relevant contemporary composers interviewed in this study: Australian composers Judy Bailey, Stuart Greenbaum, Mark Isaacs, Andrea Keller, and South African composer Stefans Grové. The aim is to identify the existence of fusion in the art music composed by the above mentioned composers and to determine the kind of fusion. Enquiries are being conducted into a composer’s body of work, whether or not there is a specialization in a fusion of genres or whether only certain compositions feature this phenomenon. Further reference is made to the influence of American composers Pat Metheny, Lyle Mays, Maria Schneider, and Australian composers Paul Grabowsky and Carl Vine upon the accompanying composition portfolio. Composers have to employ certain compositional techniques in order to overcome difficulties in practice. Presenting classical or jazz performers with musical genres they do not normally perform can be confronting. This thesis is an evaluation of compositions, as well as innovations by composers used to overcome difficulties in fusion

A clinical and molecular investigation of two South African families with Simpson-Golabi-Behmel syndrome

Background. Simpson-Golabi-Behmel syndrome (SGBS) is an X-linked recessive overgrowth syndrome manifesting primarily in boys and characterised by macrosomia, distinctive facial features and multiple congenital abnormalities. Although this rare condition is thought to be underdiagnosed, making a diagnosis is important as affected boys have a 7.5% risk of developing visceral tumours and surveillance is warranted. Mutations in GPC3 are found in up to 70% of boys affected with SGBS.Objectives. A clinical and molecular investigation of two boys with SGBS, probands B and S, and their mothers. Documentation of the clinical phenotype could assist with diagnosis in affected boys and will lead to early initiation of tumour surveillance.Methods. Hospital folders were reviewed and clinical consultations arranged for both probands and their mothers. Molecular investigations initially searched for whole-exon deletions in GPC3 followed by gene sequencing.Results. The clinical phenotype of both probands was consistent with that previously reported in the literature. The main features pointing towards the diagnosis were macrosomia, coarse facial features and macroglossia with a midline groove in the tongue. Proband B developed a Wilms tumour. He was found to have a novel mutation causing a premature stop codon.Conclusions. This research represents the first published report of SGBS in South Africa. Early recognition and confirmation of this condition is important in order to institute tumour surveillance and assist families with accurate recurrence risks

Engaging surgeons among clinician-scientists

Since completion of the Human Genome Project at the turn of the century, there have been significant advances in genomic technologies together with genomics research. At the same time, the gap between biomedical discovery and clinical application has narrowed through translational medicine, so establishing the era of personalised medicine. In bridging these two disciplines, the clinician-scientist has become an integral part of modern practice. Surgeons and surgical diseases have been less represented than physicians and medical conditions among clinician-scientists and research. Here, we explore the possible reasons for this and propose strategies for moving forward. Discovery-driven personalised medicine is both the present and the future of clinical patient care worldwide, and South Africa is uniquely placed to build capacity for biomedical discovery in Africa. Diverse engagement across clinical disciplines, including surgery, is necessary in order to integrate modern medicine into a developing-world contextualised perspective