Unmet Surgical Need among Adults in A Mixed Urban-Rural Community in Nigeria: A Survey of 1,993 Adults Using the Sosas Survey Tool.

INTRODUCTION: Community-based prevalence studies are known to be more accurate than hospital-based records. However, such community-based prevalence studies are uncommon in low- and middle-income countries including Nigeria. Allocation of resources and prioritization of health care needs by policy makers require data from such community-based studies to be meaningful and sustainable. This study aims to assess the prevalence of common surgical conditions amongst adults in Nigeria. METHODS: A descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions in adults in a mixed rural-urban area of Lagos was conducted. The study population comprised resident members in the Ikorodu Local Government Area (LGA) of Lagos State. Data was collected using a modified version of the interviewer-administered questionnaire, the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool. Data was analysed using the REDCap analytic tool. RESULTS: Eight hundred and fifty-six households were surveyed with a yield of 1,992 adults. There were 95 adults who complained of surgical conditions giving a prevalence rate of 5%. Vast majority of reported conditions were acquired deformities (n=94) while only 1 congenital deformity was reported. Others included breast lumps, anterior neck swelling, and groin swellings. CONCLUSION: The most common surgical complaints in our setting among adults were acquired conditions of the extremities and open wounds/sores. With an estimated population of 90 million adults and approximately 1,200 orthopaedic and general surgeons respectively, the surgeon-to-affected population ratio is 1:10,000. There is a large gap to be filled in terms of surgical manpower development.

INTRODUCTION: Les études de prévalence communautaires sont connues pour être plus précises que les dossiers hospitaliers. Cependant, de telles études de prévalence communautaires sont rares dans les pays à revenu faible et intermédiaire, y compris le Nigeria. L'allocation des ressources et la priorisation des besoins de santé par les décideurs nécessitent des données issues de telles études communautaires pour être significatives et durables. Cette étude vise à évaluer la prévalence des affections chirurgicales courantes chez les adultes au Nigeria. MÉTHODES: Une étude descriptive transversale basée sur la communauté pour déterminer la prévalence des conditions chirurgicales congénitales et acquises chez les adultes dans une zone rurale-urbaine mixte de Lagos a été menée. La population étudiée comprenait des membres résidents de la zone de gouvernement local (LGA) d'Ikorodu, dans l'État de Lagos. Les données ont été collectées à l'aide d'une version modifiée du questionnaire administré par un enquêteur, l'outil d'enquête Surgeons OverSeas Assessment of Surgical Need (SOSAS). Les données ont été analysées à l'aide de l'outil analytique REDCap. RÉSULTATS: Huit cent cinquante-six ménages ont été enquêtés, ce qui a donné 1 992 adultes. Quatre-vingt-quinze adultes se sont plaints de conditions chirurgicales, donnant un taux de prévalence de 5 %. La grande majorité des conditions rapportées étaient des déformations acquises (n=94) tandis qu'une seule déformation congénitale a été signalée. Les autres incluaient des nodules mammaires, des gonflements antérieurs du cou et des gonflements inguinaux. CONCLUSION: Les plaintes chirurgicales les plus courantes dans notre cadre parmi les adultes étaient des conditions acquises des extrémités et des plaies ouvertes/ulcères. Avec une population estimée à 90 millions d'adultes et environ 1 200 chirurgiens orthopédiques et généralistes respectivement, le ratio chirurgien-population affectée est de 1:10,000. Il y a un grand écart à combler en termes de développement de la main-d'œuvre chirurgicale. MOTS CLÉS: Prévalence, Charge de morbidité, Chirurgie, Plaies.

Surgical site infection in posterior spine surgery.

BACKGROUND: Surgical site infections (SSIs) in spine surgery remain a significant cause of morbidity and prolonged hospitalization. Factors affecting SSI includes patient's comorbidities, duration of surgery, type and indication for surgery among others. We intend to document our experience in our center and highlight possible factors influencing SSI in posterior spine surgery. METHODOLOGY: All consecutive patients who had posterior spine surgeries between January 2012 and July 2014 were recruited into the study. All patients who had wound infection were noted and culture sensitivities were documented as well. Results were analysed to get the infection rate, reasons for prolonged stay on admission as well as possible contributing factors to wound infections. RESULTS: A total of 62 patients' records were reviewed with 34 males and 28 females (male:female = 1.2:1). SSI was classified as deep or superficial to the fascia. Ten (16.1%) patients were found to have an SSI with 7 (11.3%) patients having deep infections and 3 (4.8%) had superficial infection. Vertebral level operated, etiology, and diagnosis were not statistically significant for SSI. However, spinal instrumentation, surgery on cervical region and wound inspection on or before postoperative day 5 were associated with an increase in the rate of SSI. Comorbidities such as diabetes mellitus, obesity, and anemia were significant risk factors. The organisms cultured were Pseudomonas and Staphylococcus species. CONCLUSIONS: Wound infection is a significant complication of posterior spine surgery. This causes distress for both patient and surgeons alike. Uncontrolled diabetes, spine instrumentation and long duration of surgery are significant risk factors for SSI. Practices of early wound inspection, frequent wound dressing changes and not keeping to nontouch technique for changing and removing dressings are important risk factors for SSI in posterior spine surgeries that need to be changed to reduce the burden of SSI.

Improvised external ventricular drain in neurosurgery: A Nigerian tertiary hospital experience.

BACKGROUND: The most common type of hydrocephalus in developing countries is post infective hydrocephalus. Infected cerebrospinal fluid (CSF) however cannot be shunted for the reason that it will block the chamber of the ventriculo-peritoneal (VP) shunt due to its high protein content. In centers where standard external ventricular drain (EVD) sets are not available, improvised feeding tube can be used. AIM: The main focus of this study is to encourage the use of improvised feeding tube catheters for EVD when standard sets are not available to improve patients' survival. METHODOLOGY: This was a prospective study. Consecutive patients with hydrocephalus that cannot be shunted immediately for high chances of shunt failure or signs of increasing intracranial pressure were recruited into the study. Other inclusion criteria were preoperative brain tumor with possibility of blocked CSF pathway and massive intraventricular hemorrhage necessitating ventricular drainage as a salvage procedure. Standard EVD set is not readily available and too expensive for most of the parents to afford. Improvised feeding tube is used to drain/divert CSF using the standard documented procedure for EVD insertion. Outcome is measured and recorded. RESULTS: A total of 28 patients were recruited into the study over a time frame of 2 years. There were 19 (67.9%) male and 9 (32.1%) females with a ratio of about 2:1. Age ranges varied from as low as 7 days to 66 years. The median age of the study sample was 6.5 months while the mean was 173.8 months. Duration of EVD varied from 2 days to 11 days with a median of 7 while the average was 6 days. Eventual outcome following the procedure of EVD showed that 19 (67.9%) survived and were discharged either to go home or to have VP shunt afterwards while 8 (28.6%) of the patients died. CONCLUSIONS: External ventricular drain can and should be done when it is necessary. Potential mortalities could be reduced by the improvised drainage using a standard feeding tube as described.

Early decompressive craniectomy for traumatic brain injury in resource poor centres:a tertiary institution experience.

UNLABELLED: Decompressive craniectomy (DC) is the surgical management of increasing intracranial pressure (ICP) following a severe traumatic brain injury (TBI) as well as severe cerebrovascular insult. Established protocols for the use of DC include monitoring ICP and going through non-surgical methods to reduce ICP before DC which is the last resort. ICP monitors and facilities to render patients hypothermic and for inducing barbiturate coma are not readily available in resource depleted facilities, hence the need for a timely DC. DC when timely done saves lives and improves chances of survival following severe brain injury. AIMS AND OBJECTIVES: This study intends to justify early and appropriate DC in selected patients with radiological and clinical increasing ICP in resource poor centres. PATIENTS AND METHOD: A one-year prospective study of patients with severe brain injury with CT and clinical evidence of increasing ICP who had DC as the main modality of management. RESULTS: Ten patients were recruited into the study on the basis of deterioration in level of consciousness and CT evidence of raised intracranial pressure. Males were 8 (80%) and females were 2 (20%) with a ratio of 4:1. RTA accounted for 80% of aetiology of TBI. Out of the ten patients, 4 (40%) died after DC. Six (60%) of the patients survived and had cranioplasty with bone flap replacement (3), titanium (2) and acrylic (1). Two (20%) were discharged with GOS of 5, another 2 (20%) with 4 and last 2 (20%) with GOS of 3. CONCLUSION: Early decompressive craniectomy is beneficial for selected groups of patients most especially in settings where facilities for ICP monitoring and other medical options are not available.

Efficacy of endoscopic third ventriculostomy in the management of hydrocephalus in children under 2 years of age: experience from a tertiary institution in Nigeria.

BACKGROUND: The management of hydrocephalus in developing countries is challenging. Hydrocephalus is a common childhood disorder in developing countries in particular and its management is quite challenging. Ventriculoperitoneal (VP) shunt is associated with high failure rates and complications. Endoscopic third ventriculostomy (ETV) with potentially lower complication rate could improve care and reduce cost of management of hydrocephalus. OBJECTIVE: The aim of this study was to evaluate the efficacy (success rate) of ETV in children ≤2 years and to find out factors that may be responsible for good outcome of ETV. METHODS: This prospective observational study was conducted at Lagos University Teaching Hospital, Lagos. Nigeria. All consecutive children ≤2 years of age with hydrocephalus were recruited into the study. Relevant demographic and clinical data documented. All cases had ETV and were followed up to document 6 months outcome. RESULTS: A total of 34 patients (M: F ratio 1.1:1) were recruited over a 2-year period. Age, sex, presumed aetiology and image findings were not statistically significant in influencing outcome of ETV. Good outcome (defined as uneventful postoperative period, not requiring repeat ETV or VP shunt) was documented in 26 (73.5%). A total of 8 (26.5%) experienced poor outcome. Complication occurred in 2 (5.9%) as follows: Wound infection 1 (2.9%) and ventriculitis 1 (2.9%). Aetiology was divided into non post-infective hydrocephalus-20 (58.8%), post-infective hydrocephalus-5 (14.7%) and post-myelomeningocoele repair-9 (26.5%). CONCLUSIONS: This study shows that ETV success rate is high in the management of hydrocephalus in children ≤2 years in our clinical practice. Regardless of the clinical diagnosis, where the facilities are available, children with hydrocephalus will benefit from ETV irrespective of the age and aetiology in sub Saharan Africa.

Nonoperative treatment of acute traumatic spinal injuries: A prospective study.

BACKGROUND: Traumatic spinal injury is a major cause of morbidity and mortality worldwide. There is no agreed method of care. Neurological recovery in complete injury has been dismal. Aims and Objectives : The aim of this study is to determine the neurological recovery at discharge in traumatic spinal injury patients managed nonoperatively in our center. MATERIALS AND METHODS: This was a prospective descriptive study carried out on traumatic spinal injury patients managed by neurosurgical unit in our center from August 2010 to July 2013. The unit started in July 2010 with virtually no available facilities for surgical care for these patients. All patients were managed nonoperatively. The unit recorded data of the patients in accident and emergency, intensive care unit, and wards using structured proforma. Data were analyzed using Epi Info 7 software. RESULTS: There were 76 patients studied of which 57 were males and 25 were females. Fifty three were caused by road traffic accident. Nineteen were complete injury. Patients with incomplete injuries did well at discharge. Completeness of injury significantly affected the outcome. CONCLUSION: The neurological recovery in incomplete spinal injuries in our study was good, but poor in complete injury. Conservative treatment should be adopted in developing countries in patients with poor resources and in centers where facilities are not available for adequate imaging and surgical care. Trauma system is imperative in our country.

Does open guide suture technique improve the patency rate in submillimeter rat artery anastomosis?

OBJECTIVE: The anastomosis of sub-millimeter vessels is fraught with significant technical challenges even for the experienced microsurgeon. The supermicrosurgery era is increasing the demand for repair of very small vessels. Our study aims to ascertain whether the open guide suture technique provides a superior patency rate compared with conventional technique when anastomosing rat artery less than a millimeter. METHODS: Anastomosis of transected rat femoral, superficial femoral and central tail arteries were done in 24 in bred albino rats. The external diameters ranged from 0.4 mm to 0.8 mm. The repair was assigned into the Open guide suture technique group or the conventional group (n=12 in each group). The duration of repair, grade of leakage, patency of the repair at 30 min were noted and compared between the groups. RESULTS: The patency rate was 92.7% in each group. There was no statistically significant difference between the 2 groups with respect to anastomotic times, grade of leakage external diameter and type of vessel repaired (p-values >0.05). CONCLUSION: It appears open guide suture -technique simplifies repair but may not offer a better patency rate in rat arterial anastomosis under 1 mm when compared to the conventional technique.

Epidemiology and treatment outcome of head injury in children: A prospective study.

SUMMARY: Head injury in children is a major concern all over the world. The increasing level of poverty in the world is exposing more children to trauma situations. The future consequences of trauma in these children are enormous, hence prevention they say, is better than cure. AIM OF THE STUDY: The study was designed to determine the etiological pattern, age group affectation and treatment outcome in children managed for head injury in our center. METHODS: It was a prospective, descriptive and cross-sectional study of children with head injuries managed in our center from July 2010 to December 2013. Data were collected using structured proforma that was part of our prospective Data Bank approved by our hospital Research and Ethics Committee. Data were collected in accident and emergency unit, Intensive Care Unit, wards and out-patient clinic. The data was analyzed using Epi Info 7 software. RESULTS: Total of 76 children managed by the unit and followed-up to a minimum of 3 months qualified for the study. There were 42 males. The age ranged from 7 months to 18 years with a mean of 8.66 years. There were 30 adolescent/teenagers. Road traffic accident formed 63.15%. Pedestrian accident was more among preschool and school children. Thirty-seven patients had mild head injury. Sixty-six patients were managed conservatively. The commonest posttraumatic effect was seizure (15.79%). Good functional outcome (≥4) was seen in 92.1%. Mode of accident and severity of injury affected the outcome. CONCLUSIONS: The etiologies of traumatic brain injury, from our study, were age dependent with falls commonest in toddlers and pedestrian accident commonest in pre-school and school ages. The outcome of treatment was related to severity of injury.

Outcome of surgically treated non-missile traumatic depressed skull fracture.

AIMS AND OBJECTIVE: To determine the functional outcome and infection rate in patients who were surgically treated for non-missile traumatic depressed skull fractures. PATIENTS AND METHODS: It is a prospective cross-sectional descriptive study carried out on computerised tomography scanned depressed skull fractures surgically treated in Lagos University Teaching Hospital, Lagos from October 2008 to September 2009. Data were collected using structured proforma in accident and emergency, theatre, wards, and in outpatient clinic. Data collected included age, gender, occupation, type of depressed fracture, aetiology, clinicaland radiological findings, type of surgery done, complications, and outcome of treatment. Data was analysed using EPI info 2002 software. RESULTS: A total of 17 patients were studied. There were 12males and 5females. Fifteen (88.2%) of the patients were0- 40years. The aetiology was road traffic accident in 82.4% of cases. Fourteen (82.4%) of the patients had open depressed skull fractures, while 17.6% had closed depressed skull fractures. Five (29.4%) of the patients had wound infection. Two (22.2%) of thepatients operated within 48hours had wound infection, while 37.5% of those operated after 48hours had wound infection. There was no infection among patients who had primary bone fragments replaced. Fifteen (88.2%) of the patients had good functional outcome. CONCLUSION: The functional outcome in this study is good but the infection rate is high. Primary bone fragments should be replaced whenever possible as it prevents the need for cranioplasty and there is no relative risk of increased infection rate.

Spinal neural tube defects in Lagos University Teaching Hospital, Nigeria.

BACKGROUND: The incidence of neural tube defects is known to vary among regions. Very little has been reported about the incidence in Sub-Saharan Africa except for the general impression that the prevalent rates are low. OBJECTIVE: To determine the profile of patients presenting with neural tube defects in Lagos, Nigeria METHODS: We studied all patients with congenital midline back swellings presenting to one of two neurosurgical services in the state over a 5-year period to establish the incidence of spina bifida and develop demographic data. Data collected included the age at presentation, maternal age, education and parity, presence of co-existing anomalies and the social status of the parents. RESULTS: One hundred and eight patients with congenital midline swellings of the back were studied. Meningomyelocele accounted for 96% of the cases seen. Half the patients presented within the first two weeks of life and although fifty percent of mothers had ultrasound scans done during pregnancy none of the patients were diagnosed prenatally. Seventy-three percent of mothers of affected children were from a low socio-economic class. The commonest co-existing congenital anomaly was lower limb deformity (Talipes equino-varus). CONCLUSION: Spina bifida is the commonest indication for neurosurgical clinic referral with the exception of trauma in our environment. The prevalence is higher among women in the lower socio-economic groups. Improved perinatal care is required to ensure that children with such birth defects get prompt medical attention and thereby prevent worsening of an already complex problem.

Stroke mimics which complicate the clinical management of 'stroke patients'.

Not all patients presenting as 'stroke patients' have cerebrovascular disease, as some conditions mimic stroke clinically. A significant degree of misdiagnosis of stroke has been documented. Clinical presentation of patients with stroke mimics can confound emergency care physicians and lead to significant morbidity and mortality for the patient, if unrecognised. We highlight some conditions that can mimic stroke emphasising ways in which these stroke mimics can be differentiated from stroke. Correct identification and management of these conditions can reduce morbidity and mortality in 'stroke patients.

Hydrocephalus and the eyes: a teaching hospital experience.

BACKGROUND: The eye developes from prosencephalon, the primitive forebrain and hence share similar embryonic origin with brain. This gives insight into primary or secondary involvement of eyes in intra-cranial pathology. OBJECTIVE: The study was done to describe ocular findings in hydrocephalus patients and effect of intervention on the complications. METHODS: Forty one consecutive hydrocephalus patients were examined pre and post ventriculo-peritoneal shunts. Comprehensive ocular examinations included dilated fundoscopy in all cases. RESULTS: A total of 41 patients were examined with the age range of between 4 hours to 108 months and a mean age of 21 months. Onset of the hydrocephalus varies from 4hours to 108 months, with a mean of 4.1 weeks. Twenty two patients (51.2%) presented after 2 months of onset of hydrocephalus. Most common presenting complaint was enlarged head seeing in 29 patients (70.7%). CONCLUSION: A total of 12 (30%) out of 41 patients with hydrocephalus had optic atrophy. Another 10 patients had sun-setting phenomenon, 3 of these sun-setting phenomena resolved a week after ventriculo-peritoneal shunts. The ocular morbidity is high among hydrocephalus patients.

Choroid plexus papilloma in a Nigerian child: a case report.

Choroid plexus papilloma is a rare but known cause of hydrocephalus among children. We report the case of an 8 month old girl who clinically was thought to have post-infective Hydrocephalus. Cranial CT however showed an associated intra-ventricular tumour which after surgical resection was reported as a Choroid plexus papilloma. This is the first time such a case is being diagnosed at our hospital and very few cases have been documented in literature from sub-Saharan Africa. This case highlights the available treatment and good prognosis that is possible with Choroid plexus papilloma. It also highlights the need for a high index of suspicion for less common causes of an enlarging head especially when the clinical picture is not typical as demonstrated in our patient. The seeming rarity of this disease in our environment may be partly due to the limited availability of CT scanners in many centres and the paucity of Neuroradiologist and Neurosurgeons in sub-Saharan Africa.

Challenges in the organisation of a microsurgery laboratory in a low resource country.

OBJECTIVES: To highlight the problems encountered in the set up, organisation and operations of a microsurgery laboratory in a low resource tertiary care hospital in Lagos, Nigeria. METHODS: The basic infrastructural deficiencies of this setting were encountered. Significant administrative, logistic and technical obstacles needed to be overcome. The need for improvisation and flexibility in the organisation and operations of such a laboratory is highlighted. The use of locally available, cheaper variety of instruments and consumables in the microsurgery laboratories of developing countries with limited resources was demonstrated by our experience . CONCLUSION: We conclude that even in the setting of low resource tertiary centres found in many developing countries, challenges could be overcome and standard acceptable patency rates obtained in the microsurgery laboratory .

Craniopharyngioma causing visual loss in an adult.

Craniopharyngiomas are usually benign tumours, commonly seen in children. They may be locally aggressive and tend to recur after excision. The most common symptoms are headache and visual difficulties. Calcifications may be seen on computed tomography. This is a case of craniopharyngioma resulting in visual loss in an adult.