Clinical profile and outcome of surgical management of intramedullary spinal cord tumours: A single center study in a developing country.

Objective: There is as yet a paucity of data on intramedullary spinal cord tumours (IMSCTs) in sub-Saharan Africa. This study aims to define the clinical profile and outcome of management of IMSCTs in a Nigerian tertiary hospital. Methods: This is a retrospective study of all the patients who had surgery for IMSCTs in our hospital over a 14 year period. Results: There were 20 patients, 9 males, 11 females, in this study. The median age was 33 years (range = 7-78 years). The median duration of symptoms was 12 months (range = 1-120 months). Motor deficit was present in all but one (95%) of our patients. Only 25% of the patients presented in good functional status (McCormick grades I and II). The tumours were confined to the thoracic region in 10 patients (50%), while tumours in the thoracic region extending to the adjoining cervical and lumbar regions were seen in 6 patients (30%). Gross total tumour resection was achieved in 60% of the patients and subtotal resection in the remaining 40%. Astrocytoma and ependymoma were the most common tumours, each occurring in 35% of the cases. Six patients (30.0%) improved, 12 patients (60.0%) remained neurologically the same, while 2 patients (10.0%) deteriorated at the time of last follow up. The mortality rate was 15%. The preoperative functional status was a significant predictor of postoperative outcome (p = 0.03). Conclusion: Astrocytoma and ependymoma were the most common histological tumour types among our patients. Late presentation and poor pre-operative functional status were prominent features of our patients' cohort.

Surgical residents as "second victims" following exposure to medical errors in a tertiary health training facility in Nigeria: a phenomenology study.

INTRODUCTION: The "second victim" phenomenon refers to the distress and other negative consequences that physicians experience when they commit medical error. There has been increasing awareness about this phenomenon and efforts are being made to address it. However, there is dearth of information about it in developing countries. This study explored the experiences of surgical resident doctors of the University College Hospital in Ibadan, Nigeria about the "second victim" phenomenon and the support they had following medical errors. METHODS: This is a phenomenology study in which qualitative data were obtained from interviews with 31 resident doctors across 10 surgical units/departments. Interviews were transcribed verbatim, and data were coded inductively. Data were analyzed using content analysis method. Themes and subthemes were generated using axial coding. The themes were then integrated using selective coding. RESULTS: There were 31 participants and 10(32.3%) were females. All had witnessed other physicians encountering medical errors while 28(90.3%) had been directly involved in medical errors. Most of the errors were at the inter-operative stage. Prolonged work hours with inadequate sleep were identified as major causes of most medical errors. The feelings following medical errors were all negative and was described as 'stressful'. Most of the residents got support from their colleagues, mostly contemporaries following medical errors, and many viewed medical errors as a learning point to improve their practice. However, there was a general belief that the systemic support following medical errors was inadequate. CONCLUSION: The "second victim" phenomenon was common among the study group with consequent negative effects. Normalizing discussions about medical errors, reduction of work hours and meticulous intraoperative guidance may reduce medical errors and its consequences on the surgical residents. Steps should be taken within the system to address this issue effectively.

Navigating the learning curve with large and giant tumors: Initial experience with endoscopic endonasal transphenoidal resection of PitNETs.

BACKGROUND: The endoscopic endonasal approach (EEA) has progressively become the preferred choice of surgical intervention for PitNETs. However, the adoption in Sub-Saharan Africa has been low. We report our initial experience with the utility of the EEA in PitNETs particularly in large and giant tumors despite limited resources. METHODS: The study was over a 73-month period at the University College Hospital, Ibadan, Nigeria. Pre and post-operative clinical, imaging and neuro-ophthalmological findings were documented. Perioperative and postoperative outcomes were recorded. We compared the outcomes between the early 23 and later 22 patients. Data were analyzed using descriptive statistics, student's t test, Mann-Whitney U test and Chi square test at α = 0.05. RESULTS: There were 45 patients; 25(55.6%) were males. Mean age was 49.9 ± 13.4 years. Visual symptoms predominated with 12(26%) blind in at least one eye. Median tumor volume was 20.9 cm3 and mean tumor diameter was 4.09 ± 0.89 cm. 31(68.9%) had gross or near total excision. Vision improved in 31(68.9%). There were 2 procedure related mortality from CSF leak/meningitis. The mean of the tumor diameter of the earlier patients was less than that of the latter (3.84 vs 4.40 cm, p = 0.04,). The latter group also had more gross or near total resections (26.8% versus 41.5%) but this was not statistically significant. There was no difference in postoperative complications. CONCLUSIONS: EEA remains a veritable option for PitNETs, including for large and huge tumors, even within resource challenged environments, with acceptable limits of complications.

The Burden of Neurosurgical Diseases in a Rural Southwestern Nigeria Setting.

BACKGROUND: Most of the few neurosurgeons in Nigeria are clustered in the urban centers. Consequently, a large proportion of the population who live in the rural areas have no direct access to neurosurgical care. This study aims to describe the burden of neurosurgical diseases in a rural neurosurgical service in Nigeria. METHODS: This was a prospective observational study of all neurosurgical patients managed at our center between August 2018 and July 2019. Data were analyzed with SPSS version 20 (IBM, Armonk, New York, USA). RESULTS: The study cohort comprised 379 patients, including 267 males and 112 females (male:female ratio 2.4:1). The mean age was 35.71 ± 20.08 years (range, 35 hours to 100 years). More than one-half of the patients (55.6%) were age 20-49 years. Head injury was the most common presentation, occurring alone in 256 patients (67.55%) and in combination with spinal cord injury in 30 patients (7.92%). Brain tumors were present in 19 patients (5.01%), spinal cord injury in 15 patients (3.96%), degenerative spine disease in 9 patients (2.38%), and hydrocephalus in 5 patients (1.32%). Surgical intervention was performed in 21 patients (5.54%). The outcome of treatment was good in 251 patients (66.22%); 34 patients (8.97%) were referred to other facilities, 43 patients (11.35%) were discharged against medical advice, mostly because of economic reasons and poor medical insight, and 31 patients (8.18%) died. CONCLUSIONS: Trauma is the most common indication for neurosurgical care in our service. Poverty and poor medical insight remain formidable obstacles to maximizing the benefits of available neurosurgical care in developing countries.

Challenging the myth of outpatient craniotomy for brain tumor in a Sub-Saharan African setting: A case series of two patients in Ibadan, Nigeria.

BACKGROUND: The concept of modern neuro-oncology hinges on strategic innovation and refinement of procedures with the intention to enhance safety, optimize extent of tumor resection, and improve not only survival but also the quality of life as well. One of such refinements includes same-day hospital admission, as well as early discharge following brain tumor surgeries. The latter has been further stretched to same-day discharge in particular settings to reduce the risk of nosocomial infections, cut brain tumor surgery costs, and improve patients' satisfaction. We highlight the challenges and possible benefits of outpatient craniotomy in a sub-Saharan African setting portrayed by the presence of lean resources and a predominant "out of pocket" health-care financing. CASE DESCRIPTION: Outpatient craniotomy was performed in two selected patients harboring intra-axial tumors: a right temporal low-grade glioma and a left frontal metastasis. The clinical outcome proved successful at short- and long-term in both patients; complications related to surgery and same-day discharge were not reported. CONCLUSION: Outpatient craniotomy is practicable and safe in resource-challenged environments and can further make brain tumor surgery cost effective and acceptable in carefully selected patients. Further prospective studies in similar settings but involving larger groups of patients are warranted.