Median Sternotomy as a Useful Adjunct to Anterior Cervicothoracic Spine Decompression and Fixation: A Plea for Its Popularity among Spine Surgeons in West Africa.

Direct anterior approach to the cervicothoracic spine (C7-T4) for surgery can be challenging via a standard anterior cervical incision as a result of the important neurovascular structures crowding the cervicothoracic junction. Where indicated, median sternotomy provides improved access to this region of the spine for interventions. From the paucity of published literature in West Africa, this adjunct appears to be quite unpopular among spine surgeons in our sub-region. We report the presentation, preoperative evaluation, operative technique and outcome of treatment of a 66-year-old man with multiple myeloma affecting T1 with the same vertebral body collapse, who had full median sternotomy, anterior T1 decompression with C7-T2 Spinal fixation. Where indicated, an anterior trans-sternal approach to the cervicothoracic spine offers good exposure to T2/T3 vertebral body for decompression and instrumentation with minimal risks and morbidity. Spine surgeons in the West African subregion should utilize this important collaboration with thoracic surgeons to achieve satisfactory access to spine surgery within the thoracic cavity.

Anomalous cerebral venous sinus drainage.

The case discussed is a 58 year old female that presented with sudden onset of headache, a Glasgow Coma Score of 15 and no neurological deficit. Computed tomography (CT) scan of the brain did not show any evidence of haemorrhage. CT angiography revealed a left sided cerebellar ateriovenous malformation with the Digital Subtraction Angiography (DSA) also showing anomalous posterior fossa venous sinus anatomy. In this case the occipital sinus provided the only drainage pathway for both the superior sagittal sinus (SSS) and the straight sinus. Of clinical significance is during the routine method of access to midline posterior fossa surgery the occipital sinus is ligated and divided. This would have resulted in massive venous infarction. Highlighting the importance of reviewing the venous anatomy on radiological images prior to neurosurgical procedures.

Value of triple H therapy in a patient with an ischemic penumbra following subarachnoid hemorrhage: a case study.

We report the case of a 43-year-old patient with delayed ischemic neurological deficit and an ischemic penumbra, reversed with triple H therapy (hypertension, hypervolemia, and hemodilution). The patient presented with subarachnoid hemorrhage caused by an aneurysm of the anterior communicating artery. He underwent surgical clipping and developed cerebral ischemia due to vasospasm. Permanent damage to the area of ischemic brain was prevented by institution of the triple H therapy. He recovered and was discharged with no subsequent neurological deficits.

Aneurysmal subarachnoid hemorrhage in young adults.

OBJECT: The authors reviewed the management protocols for young adults who presented with subarachnoid hemorrhage (SAH) at the Regional Neurosurgery Unit in Newcastle during a study period of 9 years. Aneurysmal SAH is uncommon in the age group selected (18-39 years) and, therefore, the performance of these patients has not been extensively reported in the literature. The authors also evaluated the good-grade rebleed rate (an index of management efficiency) in this cohort of patients. METHODS: The Newcastle neurosurgical unit serves a population of close to 3 million people, and an average of 180 patients with SAH are seen each year. The majority of patients are transferred from other hospitals in the region. This study includes patients admitted between January 1990 and December 1998. A total of 1,609 patients were admitted during this period, of whom 295 (18.4%) between the ages of 18 and 39 years constituted the study population of young adults. Two hundred ninety-five young adults presented with SAH; 181 (61.4%) were women and 114 (38.6%) were men, a ratio of 3:2. Of 246 patients in whom this value was recorded, 15 (6.1%) presented with a history of hypertension, and there was an association between hypertension and the occurrence of multiple aneurysms (Fisher two-tailed exact test, p = 0.008). Thirty-five patients (11.9%) presented with a hematoma on computerized tomography scans; of these, 20 (57%) were women and 15 were men. In six patients the lesion had rebled before treatment. The good-grade rebleed rate was three (1.7%) of 178. The overall favorable outcome rate was 83.8% (Glasgow Outcome Scale [GOS] 4 and 5) and unfavorable outcome occurred in 16.2% (GOS 1-3), with a total of 40 deaths in this group (13%). Age had no influence on outcome in young adults. Comparing the outcome at discharge with the follow-up evaluation at 6 months revealed that patients in the moderate and severe disability groups continued to improve and many achieved good recovery. CONCLUSIONS: In this report the authors detail the outcome of a large number of young adults with SAH. The incidence of SAH was higher in the female population, although the ratio was not as high as previously reported. The authors have also demonstrated a progressive increase in the incidence of aneurysmal SAH with age, even in young adults. Hypertension but not age influenced the occurrence of multiple aneurysms. The good-grade rebleed rate is low, although it is not zero. Generally, a satisfactory outcome was obtained and significant continuing improvements were noted between discharge and follow-up evaluation. This reflects the power of recovery in young adults. These are people whose economic productivity and fertility are at peak levels and therefore the financial and social burden occasioned by less-than-perfect outcomes is large.

Co-existing cholesteatoma and vestibular schwannoma.

A 69-year-old man presented with a cholesteatoma in the right mastoid process and a vestibular schwannoma at the left internal acoustic meatus. Cholesteatoma co-existing with a vestibular schwannoma has not been documented previously in the contemporary literature. The clinical dilemma in the management of his progressive bilateral hearing loss is discussed. He presented with dizziness and bilateral hearing loss worse on the right side. Pressure over the mastoid process elicited vertigo and nystagmus. He had no history of previous operation or infection in the ear canal. Audiograms confirmed high-tone hearing loss. Radiological investigations revealed a symptomatic cholesteatoma on the right side and an incidental vestibular schwannoma on the left. We have elected to manage both lesions conservatively. Bilateral cholesteatoma and bilateral vestibular schwannomas have been previously reported. Co-existing lesions, as in our patient have, however, not been reported previously. The management options of his hearing loss are discussed.

Anterior decompression, fusion and plating in cervical spine injury: Early experience in Abuja, Nigeria.

BACKGROUND: We present a review of the results of the current surgical management of acute cervical spine injuries in the Federal Capital Territory, Abuja, Nigeria. This is the first detailed retrospective study on the surgical management of patients with cervical spine injuries from Nigeria. METHODS: The medical reports of patients with traumatic cervical spine and spinal cord injuries undergoing surgery from 1 August 2009 till 30 August 2010 were reviewed. Management and early results of outcome were ascertained and detailed consecutively in a prospective Microsoft Office Access(®) database (Microsoft Group of Companies). Frankel grading was used for pre- and immediate post-operative evaluation (within 48 hours). The Barthel index (BI) was used to classify patients as dependent or independent at follow-up. RESULTS: Twenty consecutive patients presented with acute cervical spine and spinal cord injuries since August 2009. Twenty anterior cervical spine decompression and fixation with an iliac graft and an anterior cervical plate (ACDF) were performed in 18 patients. All operations were performed with general anaesthesia using standard techniques but without a microscope or a high speed drill. Of the 18 patients who were operated, 4 patients died within a short period following surgical intervention. Seven patients have made a full recovery and seven remain fully dependent. Only two of the dependent quadriplegic patients have become reintegrated back into the society. CONCLUSION: The management of spinal cord injuries in Abuja is evolving. The operations were performed adequately with much limited complement of equipment. Poor intensive care therapy is a major challenge and improvements in this area of care will likely lead to better patient outcomes.

The epidemiology, diagnosis and treatment of subarachnoid haemorrhage in Nigeria: what do we know and what do we need to know?

Our goal was to review published literature on the epidemiology, diagnosis and treatment of subarachnoid haemorrhage (SAH) in Nigeria. With an estimated population of 126 million, roughly 6 million persons in Nigeria have or will develop an intracranial aneurysm in their lifetime. This study should highlight the areas requiring research and development, and facilitate future health care planning. A Medline and Embase literature review of reports on the management of SAH in Nigeria was conducted. The search terms were as follows: stroke, subarachnoid haemorrhage, intracerebral haemorrhage, brain, Nigeria, Nsukka, Ibadan, Lagos, Kaduna, Jos, Benin, Port Harcourt, Africa. All identified abstracts were reviewed for inclusion in the study. Only papers dealing with the study objectives were obtained for review of the bibliography and further analysis. Thirty articles have now been published about stroke in Nigerians. Fifteen of these either discussed SAH specifically or, in general, with other stroke subtypes (ischaemic stroke and intracerebral haematoma) or reviewed vascular intracranial anomalies such as aneurysms. The most detailed paper on this issue was published in 1970 and according to that report SAH is more common in males and prevalent in young people below the age of 40 years (68% of the patients reviewed). Worldwide improvements in medical and surgical management have not been reflected in the literature on SAH. Neurologists, stroke physicians and not neurosurgeons, treat patients with SAH in Nigeria. The results presented in this study reflect the current status of the medical and surgical management of SAH in Nigeria. Conclusive data relating to epidemiology, incidence, diagnosis, current treatment modalities and outcome of SAH in Nigeria have not been published. There is, therefore, a pressing need for further study in these areas and improvements in the management of patients with SAH.