New neurological ground broken with Guyana’s 1st partial skull transplant

…24-year-old single mother now pain free
…to be discharged by Friday

By Lakhram Bhagirat

Guyana’s neurosurgery landscape is rapidly increasing with the advent of new groundbreaking procedures being performed by its lone local neurosurgeon, Dr Amarnauth Dukhi.
The latest feat in Dr Dukhi’s catalogue is the successful partial skull transplant performed on a 24-year-old single mother from Lima, on the Essequibo Coast in Region Two (Pomeroon–Supenaam).
The surgery was hailed as historic because it is a First World procedure done in a developing Third World health sector. It was done on Saturday last at the St Joseph Mercy Hospital in Georgetown by Dr Dukhi and his mostly female team.
Dr Dukhi explained that it is necessary to give women the recognition in a field that is considered traditionally male-dominated. His assistant surgeon during the 6-hour-long procedure was Dr Anna Singh, whom he has been training for over five years. His team also included his female surgical nurses – Nurse Sharma and Nurse George, and Nurse Anesthesiologist Martina Abrams; the only other male was Dr Fernandao Ramirez – Head of Anaesthesia.
The neurosurgeon said that, for the surgery to be done, it included planning even the minutest of detail, so as to avoid any difficulty during the procedural aspect of the intervention.

Patient’s background

Analisa Latchman, mother of young Arianna Mansie, has been unable to give her daughter the attention due, owing to her constant debilitating headaches. From a young age, Latchman had an indented left forehead, and her eyes were receding into her skull. As she matured, it became more pronounced.
She had, at that time, no pains or anything that really warranted immediate medical attention. However, as she matured and reached her 20s, she started to experience constant headaches.
The pain would be so intense that she would just sit in her room and cry. She thought it was due to her receding eyes, so she visited an Ophthalmologist, who tested her eyes and told her that her vision was good in spite of the receded left eye. The doctor, nevertheless, ordered a CT-Scan, which showed very little abnormalities with her eyes.
The headaches never stopped, and only intensified. This led to Latchman’s cousin – Dr Sarah Lall Khan – advising her to travel to the city and meet with a neurologist at the Georgetown Public Hospital. She did so, and even consulted another ophthalmologist, who indicated that her vision was good. The neurologist ordered a Magnetic Resonance Imaging (MRI).
Again, there was no definitive diagnosis, and the headaches began to intensify to the point where Latchman was losing consciousness. At that point, Dr Khan intervened again, but suggested that they consult Dr Dukhi in an effort to get to the root causes of the headaches and treat the source of the pain.

Diagnosis
Dr Dukhi first saw Latchman back in June, and he was immediately able to diagnose her with craniofacial dysplasia. However, after he looked at her scans and records, he went a step further to diagnose her with one of the rarer forms of craniofacial bone disorder – craniofacial fibrous dysplasia.
According to the Orphanet Journal of Rare Diseases, fibrous dysplasia is a non-malignant condition in which normal bone and marrow are replaced by fibrous tissue and haphazardly distributed woven bone.
In Latchman’s condition, her skull and facial bones were affected, and were not as hard as normal bone; and because those ‘bones’ were soft and stringy, they were more fragile and prone to break.
Dr Dukhi explained that Latchman’s case is one of the rarer ones, because of the fact that it occurs in every 10-15 babies out of every 100,000. The symptoms of craniofacial fibrous dysplasia usually start appearing by the time the child is two years old, and indentation of the forehead and skull commences by 12 years old. As the person matures, the indentation becomes more pronounced, and by the time they are in their 20s, the pain would begin.
The neurosurgeon noted that following the epidemiological review of the case, Analisa fitted perfectly into what he would refer to as classical diagnosis.
“It was really painful to see a young lady with a small child suffering so much. This is my first experience in diagnosing this issue here in Guyana, and I knew that we had to put a lot of things in place to resolve what was happening,” the doctor noted.

Treatment plan
Throughout her life, Latchman has been treating the symptoms of her condition, but after Dr Dukhi’s diagnosis, she was now able to concretely address the root of the problem. Dr Dukhi crafted a treatment plan that was suited to her condition.
He began by ordering fresh scans, and then using the CT-Scans to recreate a three-dimensional (3D) model of the scans, so as to assess the level of surgical intervention that would be required.
“The most initial aspect of things was to create a replacement for 40 per cent of Analisa’s skull. I did a CT Scan and reconstrued it in 3D, and realised that almost 40 per cent of Analisa’s skull was sick. That osseous (bony) structure of her actual skull vault has now become fibrous, and it was pulling her facial structure into the brain, hence why she had an asymmetric facial look, where her left side was more into the brain than her right side of her face was where it should be,” Dr Dukhi explained.
The scan allowed him to conclude that an implant was necessary, so that commenced the process of sourcing one. He partnered with NeuroSpine Services Inc – located in the St Joseph Hospital’s compound – and they reached out to the parent company in Trinidad, and then to KLS Martin in the United States.
NeuroSpine Services Inc is Guyana’s premier agency for advanced spine and brain gear in Guyana, and over the years they have successfully partnered with Dr Dukhi to perform cutting edge surgeries – such as the country’s first minimally invasive brain aneurysm resection, among others.
KLS Martin then asked for a 3D reconstruction of the scans, which were provided, so that they could have begun constructing the implant to suit the specific features of Latchman.
“We were able to send that to KLS Martin, and they actually reconstructed the 40 per cent of deficit that we would have provoked during surgery in Analisa’s head. That was amazing, because that is very difficult to do without actually seeing the patient’s head, but thanks to technology and CT-Scans and MRIs, this is possible.
“Because we have these resources in Guyana, it is important that we use them and we use our human resource capacity as we continue to develop health care both in the public and private sectors,” the neurosurgeon related.

Financial hurdles
Brain surgery is generally expensive because of its particular approach as well as the risk involved. So, when Latchman was told of the surgery, she was worried about the costs, since, as a single mother, she did not have access to the level of financial resources that were required.
According to her cousin, following the initial consultation with Dr Dukhi, Latchman went home and cried because she knew her financial position did not allow for such a complex intervention.
Dr Dukhi is noted for his generous approach towards patients with financial difficulties, and in this case, he did not fail. He offered his services pro bono, and even went a step further to seek financial assistance for Latchman, so that she could have this surgery done locally at a fraction of the cost.
According to Dr Dukhi, had Latchman been forced to go overseas for treatment, he cost would have stood at a minimum of US$200,000. During this procedure, she paid only US$11,000 (just over Gy$2 million) for the implant, and the rest was covered by donations.
“I am very happy to do this surgery pro bono for Analisa, because it is what I love doing,” he said.
Dr Dukhi approached the Administration of St Joseph Mercy Hospital for assistance, as well as local businessman and Vice-Chair of the Hospital’s Board, Chris Fernandes, who offered to cover the hospital costs for Latchman’s surgery.
Fernandes related that he was contacted in July by a friend seeking assistance for Latchman, and he immediately contacted Dr Duhki to find out about the process. He hailed the relatively young doctor as one of the gems in Guyana, as well as his knack for pushing the surgical capabilities of the country’s health sector.
He explained that his role was getting the hospital to give them the minimal cost for doing the surgery, and then getting that funded by anonymous donors and himself.
“Thanks to Dr Dukhi for doing that, and for setting the bar as high as you have for others to emulate,” he said.
Other donors and private sector bodies pitched in to make the historic surgery a reality. Additionally, Dr Dukhi got his assistant surgeon and anesthesiologist to perform the surgery pro bono.

Surgical intervention
“The issue with Analisa’s reconstruction, replacement of her skull, was that it involved 3 bones; it involved the frontal bone, the parietal bone and the temporal bone of her left side of her head. Three major issues, and her symptoms were due to the involuting or convoluting reduction of her skull, which was squeezing the frontal lobe of her skull,” he said.
He explained that the frontal lobe is responsible for behavioural patterns, and it is one of the lobes that provoke the Jacksonian type of seizures, so Latchman was likely to have permanent brain damage over the next couple of years. While he could not have gauged how long before onset of the permanent brain damage, Dr Dukhi said Latchman would have been prone to ischemic changes to the brain due to the continuous pressure from an involuting or convoluting skull vault.
During the six-hour-long surgery, Dr Dukhi and his team were able to remove the 40 per cent sick skull from Latchman, and transplant the implant. The implant arrived in Guyana on Thursday last, and the surgery commenced on Saturday at 07:00h.
“It was a very technical surgery, because we had to go all the way on the eye at the orbit. Imagine part of her eyes is now into her brain, and we were able to reset her orbit where it was. So, if you look at Analisa now, she actually had a nice-looking forehead, not that indented forehead anymore. Her orbit is back in place, and she has good vision. It was tedious for me, because it has two very important nerves that come out, which is the facial nerve and the upper branch of the trigeminal nerve. We were able to dissect that very carefully, and protect it so there were no injuries to her nerve, so there were no repercussions in terms of who she was and her normal functions,” he noted.
There is a thin layer that usually covers the brain, it is called the dura, and Dr Dukhi, even before surgical intervention, knew that he had to tread carefully around the dura. When he opened Latchman up, he discovered that the dura was already thinning owing to the compression of the skull.
This presented somewhat of a challenge, since he had to be extra careful in removing the skull, because if the dura is damaged, then that leads to brain damage.
“We had what we called a bicoronal approach to her skull, and we were able to expose, due to that approach the frontal bone, the periorbital bone and the temporal bone, and that was resected so all of her sick skull was removed,” he said.
The implant was transplanted with minor adjustments.
Overall, Dr Dukhi said, the entire process was a smooth one, with no surgical complications.

Risks
Brain and spinal surgery carries a heavy risk, with the worst-case scenario being death. In Latchman’s case, Dr Dukhi had to be extremely careful with the nerve damage, particularly facial nerve damage.
Had he been unable to resect the upper branch of the V1 branch of the trigeminal nerve, then she would have ended up with trigeminal neuralgia which would have left her with pain for the duration of her life.
Additionally, nerve damage would have also caused paralysis on the left side of her face.
“So, I had to find those nerves and dissect it away from the surgical approach, and that was done successfully” he noted.

Healthy life ahead
Latchman is now making a full recovery, and has already expressed that she no longer has headaches. She is expected to be discharged today or Friday the latest, according to Dr Dukhi.
He noted that he cannot foresee any complications with Latchman at this time, and that she can experience a healthy, normal life now.
The single mother, speaking with the media via Zoom, expressed her gratitude to Dr Dukhi, the surgical team, the hospital, as well as businessman Fernandes. She added that donations locally and from overseas were able to cover her end of the costs, and for that she is grateful.
Latchman is now on the path to making a full recovery, and says she cannot wait to get back to work, so that she can provide for her daughter and herself. (G2)