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 Table of Contents  
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 59-64

Issues in medical tourism: A presentation of three patients with degenerative spine diseases

Department of Surgery, Orthopaedic Unit, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria

Date of Web Publication12-Feb-2016

Correspondence Address:
Mohammed Kabir Abubakar
Department of Surgery, Orthopaedic Unit, Aminu Kano Teaching Hospital/Bayero University, P.M.B. 3011, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0331-8540.176043

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Introduction: Patient seeks medical treatment abroad for several reasons. It may be due to lack of expertise or lack of adequate equipment to handle the ailment in the country of abode. However, some may be due to social reasons or due to privileges that come with some social status and position. The study is justified by the need to high light some of the problems encountered by patients after treatment abroad. Materials and Methods: The case notes of three patients seen at the orthopaedic outpatient clinic were retrospectively reviewed. These patients had initially presented with different clinical problems. Data on their clinical history, examinations, investigations and treatment were extracted from their case note. Result: The first patient is a 53-year-old civil servant with clinical and radiological evidence of L4–L5 and L5–S1 disc degeneration with prolapse and neuropathy. He was cancelled for decompression and fusion. He opted to travel abroad for treatment. He represented few months later with the same complaint despite surgical treatment abroad. He had no physical evidence of what procedure was done. A second patient is a 68-year-old man with multilevel disc prolapsed and associated lumbar the canal stenosis. He was given the option of decompression with fusion. He opted to travel abroad, where he had L2–L5 laminectomy with pedicle screw stabilisation spanning three levels using four screws and two rods. His symptoms persisted despite procedure. He had evidence of the wrong choice of procedure. He is presently on conservative management as he does not want surgery. The third patient is a 50-year-old politician who presented with a painful gluteal swelling. She had transforaminal lumbar interbody fusion at L4–L5 with L2–S1 and laminectomy with L2–S1 pedicle screw stabilisation done abroad about 1 year before presentation. The indication being L4–L5 spondylolisthesis with L2–S1 multilevel disc prolapsed. She was found to have dislodged migrated rod. The rod was surgically extracted. Discussions and Conclusion: The First patient had the wrong/suboptimal procedure done to him. As such, he continued to have persistent pain. He cannot afford to go for appropriate procedure abroad. He is being planned for decompression and fusion. The second patient had suboptimal procedure. His pain continued. He could not afford to go for follow-up and re-evaluation. He also does not want any reoperation. He is now conservative management. The second patient had appropriate procedure done. However, she developed a technical complication which was not addressed appropriately. She had surgical extraction of the migrated rod and had done well.

Keywords: Degenerative, medical tourism, spine

How to cite this article:
Abubakar MK, Adamu KM. Issues in medical tourism: A presentation of three patients with degenerative spine diseases. Niger J Basic Clin Sci 2016;13:59-64

How to cite this URL:
Abubakar MK, Adamu KM. Issues in medical tourism: A presentation of three patients with degenerative spine diseases. Niger J Basic Clin Sci [serial online] 2016 [cited 2023 Mar 31];13:59-64. Available from: https://www.njbcs.net/text.asp?2016/13/1/59/176043

  Introduction Top

Medical tourist elects to travel across international boundaries to seek for medical treatment. It may span the full range of medical services from dental care, cosmetic surgery, fertility treatment and many more.[1] The realm of medical tourism is quite difficult to define as it is diverse as the treatment patients seek. While some countries include foreign patient's visits to hospitals, others count the entry of individual the country.[1] Medical tourism is the term used to describe people travelling outside their home country for treatment.[2] The main reason for medical tourism is better quality care for medically necessary procedure, quicker access to medically necessary procedure, lower cost for medically necessary procedure and access to most advance technology.[1] Traditionally, medical tourist travel from less developed to a more developed countries to seek better care. While this trend still remains, there is a high surge of the patient from the developed countries such as USA, Britain to middle-income countries such as India to access technically challenging procedures due to less cost and reduce waiting time.[3] In developing countries such as Nigeria, the motivation to travel abroad is largely to access better health service due to the paucity of a super specialist. The incessant industrial disharmony with the health sector has eroded the confidence of the public on the quality of care in Nigerian Hospitals.

Our study seeks to highlight some problems face by the unsuspecting patient while seeking medical care abroad such as been attended to by incompetent health personnel or having inappropriate treatment.


To highlight some problems and challenges faced by patient following treatment abroad.

  Materials And Methods Top

The study was a retrospective study. Information from case records of three patients presenting to the Orthopaedic Outpatient Clinic of Aminu Kano Teaching Hospital Kano with complaints following surgical treatment abroad for degenerative spine diseases was obtained. No ethical clearance was obtained for the cases reported.

Detail history, examination and investigation were extracted from the patient's case records. Verbal clarification was sorted where necessary. The peculiarities of each patient were noted and the problems they encountered were highlighted.

All the three patients had initially consulted a specialist in Nigeria before opting for treatment abroad. They all travelled on self-referral.

Patient 1

IT is a 53-year-old civil servant that initially presented on 12th November 2013 to the Orthopaedics Outpatient Clinic of Aminu Kano Teaching Hospital with low back pain and radiculopathy of 4 years duration. There were features of neurogenic claudication. He had a stooping gait. Straight leg rising was 0–60° bilaterally. Hamstring tightening and positive sciatic stretch test. There was no obvious back deformity. He had tenderness in the lumbosacral region. Muscle tone, bulk and reflexes were normal. His complete blood count, clothing profile, electrolyte and sugar were within normal limit. X-ray showed reduced L4–L5 and L5–S1 disc space with end plate sclerosis and osteophytes [Figure 1] and [Figure 2]. Magnetic resonance imaging (MRI) revealed L4–L5 and L5–S1 disc degeneration and prolapse. There was thecal compression at L4–L5 and L5–S1 level [Figure 3] and [Figure 4]. He does not have other comorbidity. He was cancelled for decompression and transforaminal lumbar interbody fusion (TLIF).
Figure 1: Patient 1 - Lumbosacral X-ray lateral

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Figure 2: Patient 1 - Lumbosacral X-ray anteroposterior

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Figure 3: Patient 1 - Pre-operative magnetic resonance imaging sagittal

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Figure 4: Patient 1 - Pre-operative magnetic resonance imaging

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The patient then absconded. He was said to have travelled abroad for treatment. While abroad, he had a procedure done at the back. The procedure was carried out under general anaesthesia. He does not know what procedure was done.

He initially did well. However, 2 months later his previous symptoms reoccurred. This necessitates his representation to orthopaedic outpatient clinic 2 months after the procedure. He was re-evaluated. He was not given any formal medical report by the attending hospital abroad. Hence, we could not ascertain the procedure he had. His clinical examination was no different from is initial presentation. Back examination did not reveal any evidence of a surgical scar on his back. Repeat investigations including MRI were essential as the first one he had before travelling abroad for treatment [Figure 5]. He was subsequently billed for decompression and TLIF. He is yet to have his procedure.
Figure 5: Patient 1 - Post-operative magnetic resonance imaging

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Patient 2

MA is a 68-year-old man who presented to the orthopaedics outpatient clinic on the 4th of December 2013 with low back pain of over 8 years duration. He had associated Neuropathic claudication. He has had back surgery abroad 1 year before presentation for the same problem. Pain had reoccurred after initial relieve.

He does not have resources to go for follow-up. No other contributory factors. His clinical Examination revealed healed midline surgical scar at lower back. He had the limitation of straight leg raising. He also has a positive sciatic stretch test. He had normal muscle bulk, tone and reflexes. There was no neurological deficit. He was investigated. X-ray showed loss of lumbar lordosis and multiple disc space narrowing. There was evidence of laminectomy spanning L2–L5 with pedicle screw stabilisation. The instrumentation spans three levels thus L2–L3, L3–L4 and L4–L5. Four screws and two rods were used [Figure 6] and [Figure 7]. MRI could not be done due to the presence of metallic hardware in the back. An assessment of multilevel degenerative disc disease was made.
Figure 6: Patient 2 - Lumbosacral magnetic resonance imaging anteroposterior

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Figure 7: Patient 2 - Lumbosacral X-ray lateral

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He does not want revision surgery as he cannot afford it either in Nigeria or abroad.

He was managed with analgesics and muscle relaxants and physical therapy. He has done fairly well as pain and radiculopathy have improved.

Patient 3

MH is a 53-year-old Female politician who presented to the Orthopaedic Outpatient Clinic of Aminu Kano Teaching Hospital, with left gluteal pain and swelling of 3 months duration. Pain was severe enough to prevent her from sitting on the left buttocks. No constitutional complain. She had a history of posterior decompression and fusion in hospital abroad 1 year before presentation. The indication being multilevel lumbar disc degeneration and prolapse worst on L4–L5 disc.

Her examination revealed midline surgical scar at the lower third of the back. There was a limitation of full flexion and extension of the back due to pain. There was a tender left gluteal swelling that was hard and mobile. It was not attached to skin or underlying tissues.

X-Ray showed in-situ pedicle screws and rod in the back, spanning L3–S1. Absent of rod on the left side was noted [Figure 8] and [Figure 9]. There was a free lying rod in the soft tissue of the left gluteus. An assessment of loose left side rod with gluteal migration was made.
Figure 8: Patient 3- X-ray lateral lumbosacral showing migrated rod at gluteal region

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Figure 9: Patient 3 - Lumbosacral X-ray AP with dislodge rod on the left side

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She had surgical removal of the rod under local anaesthesia [Figure 10] and [Figure 11]. She did well. She is now able to sit with no pain on the left gluteus [Figure 12] and [Figure 13].
Figure 10: Patient 3 - Surgical incision site

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Figure 11: Patient 3 - Removed migrated rod

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Figure 12: Patient 3 - Post-operative X-ray 1

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Figure 13: Patient 3 - Post-operative X-ray 2

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  Results Top

All three patients opted to travel abroad on self-referral.

First patient IT:

  • Had a poorly defined procedure based on the post-operative clinical and radiological findings
  • No medical report given to indicate the procedure that was done
  • Patient's problem persisted despite the procedure
  • Both pre- and post-procedure clinical evaluation and investigations were essentially the same
  • He could not afford to go for review with the physician that did the initial procedure.

Second patient MA:

  • Patient could not afford revision of procedure abroad
  • Posterior stabilisation was done, but multiple levels were skipped and not instrumented
  • Symptoms reoccurred shortly after the procedure.

Third patient MH:

  • She had appropriate procedure for her condition
  • She had technical complication from procedure
  • Complication developed at a time that was not convenient for the patient to travel for re-evaluation.

  Discussion Top

The first patient had a poorly defined procedure based on the post-operative, clinical and radiological findings. One was tempted to say that no procedure was done. Because most medical tourists have no prior knowledge of the country they are seeking heath care, they make use of intermediaries to facilitate their treatment abroad. Thus, they risk possibilities of falling into the hands of quarks or inappropriate physicians.[4],[5]

Posterior decompression with fusion and pedicle screw stabilisation is a well-known procedure for patients with multilevel degenerative lumbar disc degeneration.[6],[7],[8] The incorporation of more than one spinal segment as a single construct is very unstable.[9] This is because it aggravate further disc degeneration, accelerates adjacent segment disease and symptoms are not alleviated. The procedure done for our second patient is, therefore, not appropriate.

Both first and the second patient had wrong/suboptimal procedure.[10],[11]

This was corroborated by the persistent pain and neuropathy.[12] It is standard to obtain informed consent before every surgical procedure.[13],[14] The claim by the first and second patient that they were not aware of the procedures carried out on them may be due to communication gap or due to high patient expectation associated with surgery abroad.[7],[15],[16],[17],[18]

Perhaps the biggest challenge was the fact that the patients could not afford to go back for further review by the primary surgeon. Thus, the burden of treatment and care lies with the physicians at the home country. Barring ethics, these physicians may not be comfortable attending to the patient that are presenting to them as a necessity not because they have confidence with the system.[19] The third patient had an appropriate procedure done.[20] However, she developed a technical complication. The rods had loosen and migrated to the left gluteal region. Rod migration following posterior stabilisation with rods had been described both for pedicle screw and Harrington's rod.[21],[22],[23] Even though she could afford to travel for review, the timing was not conducive for her. She had a minor procedure which had relieved her of pain and discomfort. It had also relieved her of social and financial stress involve in travelling abroad.

Nigeria loses about 46 billion Naira ($255 million) to medical tourism annually.[24] This amount does not reflect the man hours involve in preparation, travel to and fro, and the stress involves in the whole process. Contemporary debate over current and potential benefit of medical tourism will continue as long as there is no improvement in health care delivery.[25]

  Conclusion Top

Medical tourism has greatly assist patients in accessing modern and appropriate treatment. It is, however, not without some problems. Patients and physicians need to be abreast with where and who is attending to them or their patient so as to avoid falling into the hands of inappropriate personnel, as our first and second patient experienced. Collaboration between local physician and the attending physician abroad is also necessary so that complications can be identified early and addressed. This will ease the stress on a patient that requires follow-up for his/her condition or following some complication of the procedure.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med 2014;21:410-7.  Back to cited text no. 3
Rebecca I. Medical Tourism in Nigeria: Buyer Beware. Centre for Health Ethics Law and Development; 16 May, 2013. Available from: http://www.cheld.org/articlec. [Last cited on 2013 May 16].  Back to cited text no. 4
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Phillips FM, Slosar PJ, Youssef JA, Andersson G, Papatheofanis F. Lumbar spine fusion for chronic low back pain due to degenerative disc disease: A systematic review. Spine (Phila Pa 1976) 2013;38:E409-22.  Back to cited text no. 6
Polly DW Jr., Santos ER, Medob AA. Surgical treatment for the motion segment matching technology with indications, posterior fusion. Spine 2005;30:S44-51.  Back to cited text no. 7
Berjano P, Lamartina C. Classification of degenerative segment disease in adults with deformity of the lumbar or thoracolumbar spine. Eur Spine J 2014;23:1815-24.  Back to cited text no. 8
The Burton Report: Pedicle Screw Segmental Instrumentation. Available from: http://www.burtonreort.com/insf/surgstabilpedscrews.htm. [Last cited on 2015 Dec 31].  Back to cited text no. 9
Vaccaro AR, Ball ST. Indications for instrumentation in degenerative lumbar spinal disorders. Orthopedics 2000;23:260-71.  Back to cited text no. 10
Sidhu KS, Herkowitz HN. Spinal instrumentation in the management of degenerative disorders of the lumbar spine. Clin Orthop Relat Res 1997;(335):39-53.  Back to cited text no. 11
Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: Review of the literature. Spine (Phila Pa 1976) 2004;29:1938-44.  Back to cited text no. 12
Anderson OA, Wearne IM. Informed consent for elective surgery – What is best practice? J R Soc Med 2007;100:97-100.  Back to cited text no. 13
General Medical Council (UK). Seeking Patients Consent: The Ethical Consideration. London: GMC; 1998. p. 1-12. Available from: http://www.gmc-uk.org/. [Last cited on 2009 May 28].  Back to cited text no. 14
Grewal I, Das JK, Kishore J. Expectation and satisfaction of medical tourist attending tertiary care hospital in New Delhi, India. JIMSA 2012;25:3.  Back to cited text no. 15
Prakesh M, Tyagi N, Devarath R. A Study of Problems and Challenges Faced my Medical Tourist Visiting India. The Indian Institute of Travel and Tourism Management; February, 2011.  Back to cited text no. 16
Johnston R, Crooks VA, Snyder J, Kingsbury P. What is known about the effects of medical tourism in destination and departure countries? A scoping review. Int J Equity Health 2010;9:24.  Back to cited text no. 17
Malik K. Treatment of multilevel degenerative disc disease with intradiscal electrothermal therapy. Anaesth Intensive Care 2007;35:289-93.  Back to cited text no. 18
Doyle BJ, Ware JE Jr. Physician conduct and other factors that affect consumer satisfaction with medical care. J Med Educ 1977;52:793-801.  Back to cited text no. 19
Abioye Kuteyi EA, Bello IS, Olaleye TM, Amedi M. Determinants of patient satisfaction with physician interaction: A Cross-sectional survey at Obafemi University Health Centre, Ile Ife Nigeria. S Afr Fam Pract 2010;52:557-62.  Back to cited text no. 20
Konuralp I, Nezih Y, Gul I, Volkan E. Migration of a lumbar Rod to posterior sacral region: An extremely unusual complication of spine surgery. J Neurol Sci 2014;31:1.  Back to cited text no. 21
Obeid I, Vital JM, Aurouer N, Hansen S, Gangnet N, Pointillart V, et al. Intraspinal canal rod migration causing late-onset paraparesis 8 years after scoliosis surgery. Eur Spine J 2014. [Epub ahead of print].  Back to cited text no. 22
Agrawal A. Pedicle screw nut loosening: Potentially avoidable causes of spine instrumentation failure. Asian Spine J 2014;8:224-6.  Back to cited text no. 23
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Ormond M, Mun WK, Khoon CC. Medical tourism in Malaysia: How can we better identify and manage its advantages and disadvantages? Glob Health Action 2014;7:25201.  Back to cited text no. 25


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]


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