Challenges and strategies in the surgical management of traumatic spinal cord injuries in the Democratic Republic of the Congo.

BACKGROUND: Significant progress has been made in the management of traumatic spinal cord injuries. However, deep disparities persist in developing countries. This work aims to describe the different challenges in the surgical management of traumatic spinal cord injuries at the Kinshasa University Teaching Hospital and some strategies implemented to overcome them. METHODS: This is a cross-sectional study of 105 patients from January 2016 to June 2023. The variables of interest included: gender, age, cause, levels of lesion, hospital admission modalities, time to admission, time to surgery, AIS score at admission and on discharge, treatment, pre, peri- and post-operative complications and outcome. RESULTS: We admitted 105 patients. Only 16 % of them were taken to hospital in an ambulance. The average admission time was 49.9 ± 81.79 days. Seventy-two patients (68.6 %) were operated. The average time to surgery was 62.43 ± 85.20 days. No patient was stabilized at the trauma site. Osteosynthesis was performed with appropriate implants in 63.2 % and with improvised elements in 26.8 %. Four patients were operated without an image intensifier. Short-segmental fixation was performed in 8 patients. Twenty-one patients developed pressure ulcers. At discharge, 24 patients recovered their neurological function. Neurological status remained stationary in 43 patients. Five patients died. Seventeen patients went to rehabilitation center. There was no significant difference between the improvised strategies implemented and conventional procedures on functional recovery upon discharge from hospital or rehabilitation centre (p-value : 0.838 and 0.468 respectively). CONCLUSION: Our establishment faces many challenges in TSCI surgery: lack of pre-hospital emergency services and mutual health insurance, delay in admission, lack of surgical implants and image intensifier, the poverty of the population. Some strategies have been implemented to overcome some of them.

Neurocysticercosis in a Nigerian woman -missed diagnosis of a neglected disease and surgical management.

Neurocysticercosis is a rarely diagnosed but significant clinical problem from infestation with taenia solium. It occurs as a result of ingestion of infested pork and the mode of transmission is usually feco-oral. It is commonly associated with non-specific neurologic manifestations expected of intracranial space-occupying lesions with its most common neurological presentation being seizures. However, its diagnosis without seizure is rarely reported. We report a recent experience in this regard and outcome of this disease which was inadvertently managed surgically. A good history and high index of suspicion especially in developing and low socioeconomic region is helpful for diagnosis in the presence of appropriate radiological findings. Prognosis is good when treatment is tailored to well selected cases. Treatment options include medical with or without surgical removal of encapsulated cyst. A high index of suspicion will be helpful in making appropriate diagnosis and proper management of this disease.

Surgical management of Aneurysmal Subarachnoid Haemorrhage in a resource-constrained region: A Nigerian regional experience.

Background: Aneurysmal Subarachnoid Haemorrhage (aSAH) is a vascular injury with significantly high mortality, especially when poorly managed. This study seeks to outline the experiences in setting up a neurovascular service in Lagos, Nigeria. Methods: A series of 45 patients were operated after aSAH over a period of 10 years. Patients consecutively were recruited following computed tomography angiography (CTA) diagnosis of aSAH. Clinical data were recorded on a predesigned form after obtaining informed consent; aSAH was classified using the WFNS classification, intraoperative findings were documented. Challenges in the management were analysed in a post-operative root cause analysis (RCA) review. Outcomes and factors responsible for the observed outcomes and actions taken were recorded. Results: Forty-five patients were operated after aSAH was confirmed; there were 29 females and 16 males. (M:F 1:1.8), the age ranged from 14 to 76 years (mean 49.1±13.58). All the aneurysms were on the anterior circle of Willis, mainly on Anterior Communicating Artery aneurysm (18/48).Thirty-eight patients (84.4%) survived and were discharged within an average of 10 days after surgery. Lower GCS at presentation was associated with poor prognosis (p = 0.026); however, data analysis demonstrated that other factors (financial issues, lack of appropriate instrumentation and equipment, experience of the surgeon) played a significant role in determining the outcome. Conclusions: Aneurysmal Subarachnoid Haemorrhage (aSAH) is a challenging pathology and its management may be further burdened in resource constrained countries, as shown by the data analysed in this study from Lagos, Nigeria. Specialized and well-funded Neurovascular centres are needed to overcome the challenges faced and to improve care for aSAH patients in Nigeria.

Improvised intracranial pressure monitoring devices for traumatic brain injury management in a low-income environment: A single-centre randomised study demonstrating feasibility.

Background: The high cost and non-availability of standard ICP monitoring devices limit their use in low- and middle-income countries like Nigeria. This study aims to demonstrate the use of an improvised intraventricular ICP monitoring device as a feasible alternative. Research question: Are improvised ICP Monitoring devices feasible and effective in resource-constrained settings? Materials and methods: The study was a prospective single-institution investigation involving 54 adult patients that presented with severe TBI (GCS of 3-8) within 72 â€‹h of injury and required operative intervention. All patients underwent craniotomy or primary decompressive craniectomy (DC) to evacuate traumatic mass lesions. 14-day in-hospital mortality was used as a primary endpoint of the study. 25 patients had ICP monitoring postoperatively using the improvised device. Results: The modified ICP device was replicated using a feeding tube and a manometer with 0.9% saline as a coupling agent. Based on hourly ICP recording (up to 72 â€‹h), patients were observed as having high ICP (>27 â€‹cm H2O) and normal ICP (27 â€‹cm H2O). In the ICP-monitored group, raised ICP was detected more than in the clinically assessed group (84% vs 12% p= <0.001). Discussion and conclusion: There was a 3-time higher mortality rate among the non-ICP monitored participants (31%) compared to the ICP-monitored participants (12%), although this did not reach statistical significance due to the small sample size. This preliminary study has shown that this modified ICP monitoring system is a relatively feasible alternative for diagnosing and treating elevated ICP in severe TBI in resource-constrained environments.

Sellar brain tumour co-existing with a left posterior communicating aneurysm causing ptosis: lessons learnt (case report).

Posterior communicating aneurysm (PCOM) commonly presents with ptosis of the eye. This is so also with space occupying lesion compressing the oculomotor nerve. It is quite uncommon for a patient to have both lesions at the same anatomical space concurrently causing ptosis. If undiagnosed before surgical intervention, surgical complications from such a complex neurosurgical problem can be extremely devastating. We share our recent experience with confusing clinical presentation and subsequent treatment of a sellar brain mass co-existing with a left posterior communicating artery aneurysm at the same location in a 48 years old woman who was successfully managed with left pterional craniotomy and clipping of the PCOM aneurysm followed by gross total excision of the lesion. She improved with full resolution of left ptosis within 2 months. The histology revealed WHO Grade 1 psammomatous meningioma. Although similar sorts of pathologies occurring together have been described in the literature, this unique experience underscores the importance of thoroughly evaluating neurosurgical cases clinically irrespective of findings from radiologic investigations in order to prevent unexpected intra-operative disasters and embarrassment. Moreso, this is important particularly in Africa where advanced investigations to easily identify such complex pathologies are not readily available.

Proposal of a Novel Anatomic Guide to the Sphenoid Sinus.

BACKGROUND: Landmarks for transsphenoidal surgery have been described to facilitate resection for pituitary lesions. However, carrying out sphenoidotomy for access to the sellar floor could still be challenging, especially for young surgeons during the steep learning curve. OBJECTIVE: We describe the LUTH (Lagos University Teaching Hospital) line as a simple anatomic guide to avoid missing the trajectory to the sella during anterior sphenoidotomy in microscopic transsphenoidal pituitary surgery. METHODS: We identified this line as an impression on the floor of the sphenoid sinus across the point at which the floor of the anterior cranial fossa and the bony projection from the clivus meet. We carried out a literature review of articles describing landmarks for anterior sphenoidotomy using data obtained from PubMed and Ovid MEDLINE databases according to PRISMA guidelines. RESULTS: A total of 80 patients were operated using the LUTH line as a guide for anterior sphenoidotomy during microscopic transsphenoidal pituitary. We did not find any previous description of this anatomic landmark over the anterior sphenoid sinus in the literature. The LUTH line was clearly identified in all 80 cases. The line was used as a bony landmark to the sphenoid sinus in all cases and was found to be consistently accurate. CONCLUSIONS: The LUTH line is a consistent and easy-to-identify landmark that could be useful in preventing potential complications of access to the pituitary sella through the sphenoid sinus. We believe it to be useful in the absence of intraoperative guidance, especially for young surgeons who are just starting off their career in pituitary surgery.

Contemporary Management of Intracranial Subdural Empyema: An Institutional Experience.

Background: Intracranial subdural empyema (SDE) is a seemingly uncommon life-threatening ailment with varying presentations and outcomes. A variety of risk factors have been associated with predisposition to intracranial SDEs; however, they may be cryptogenic. There is an increased predilection for intracranial SDE in children and teenagers with paranasal sinusitis or middle ear infections. The clinical presentation is non-specific and thus a high index of suspicion is required. Neuroimaging is an invaluable diagnostic tool for early diagnosis and surgical intervention. There have been multiple proponents for either burr hole or craniotomy to treat intracranial SDEs; however, despite surgical intervention, adverse neurologic sequelae and even mortality still occur. Extended antibiotic therapy is mandatory and impacts significantly on patients' outcomes. Objectives: This study describes the demographics, clinical presentation, and surgical outcomes in patients with intracranial SDEs over the study period. Design: This is a retrospective single-centre case series. Setting: This study takes place in a tertiary referral centre, university hospital. Materials and Methods: This was a retrospective review of patients presenting with intracranial SDEs over a 10-year period in a tertiary neurosurgical unit serving south-western Nigeria. Demographic, clinical, and radiologic data were retrieved from patient records. Results: Forty-nine patients presented with intracranial SDEs during the review period. These patients aged between 16 months and 75 years, most of whom were 20 years of age and below. The mean age was 21.37 ± 19.29 years with a median age of 15 years. There were 35 males and 14 females giving a male-to-female ratio of 2.5:1. The most common presentations were headache (73.5%), altered sensorium (55.1%), and seizures (38.8%). Forty patients (81.6%) had evacuation of SDE by burr hole and subdural washout. There was a significant post-op residual SDE in six patients. There were eight (16.3%) mortalities in this series. Forty-seven (95.9%) patients had sterile cultures of the subdural pus collection. Conclusion: Intracranial SDE affects mostly children and teenagers. Early diagnosis, emergent surgery, extended antibiotic therapy, and concurrent source control employing a multidisciplinary approach are essential in managing this condition. Burr hole and subdural washout help control the disease process, reduce operation time, and may yield outcomes similar to craniotomies, which are more invasive.

Strategies for Treatment of Multiple Brain Aneurysms Without Intraoperative Adjuncts.

BACKGROUND: Although fairly rare, multiple brain aneurysms are well known to occur in certain conditions such as arteriovenous malformations, coarctation of the aorta, renal artery stenosis, adult type 3 polycystic kidney disease, as well as connective tissue disorders (such as Ehlers-Danlos syndrome, Marfan syndrome, and fibromuscular dysplasia). Increased incidence of complications of surgery in such situations is expected to be more likely than in surgery for a single aneurysm, particularly in the absence of intraoperative guidance with adjuncts. METHODS: We report a case of an anterior communicating artery aneurysm, a right middle cerebral artery aneurysm, and a right pericallosal aneurysm in a 70-year-old man. All 3 aneurysms were clipped through a single-stage approach without the aid of any adjuncts such as micro-Doppler ultrasonography, indocyanine green videoangiography, or intraoperative digital subtraction angiography. We carried out a literature review for past publications on similar reports. RESULTS: The patient made a complete postoperative recovery and sustained no neurologic deficits. Out of 388 publications from the literature search, only 1 case report described clipping of 2 tandem aneurysms in a 60-year-old woman without mentioning any intraoperative adjuncts. CONCLUSIONS: This case illustrates that multiple aneurysms can actually be safely operated with adequate planning in the absence of these adjuncts, especially in resource-poor regions. This is particularly crucial in Africa and most low-and-middle-income countries, where such facilities and equipment are not common.

Early Outcome of Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization Versus Ventriculoperitoneal Shunt as Primary Treatment of Hydrocephalus in Children With Myelomeningocele: A Prospective Cohort Study.

BACKGROUND: Myelomeningocele is associated with hydrocephalus in 35% to 90% of cases. Hydrocephalus is usually treated with insertion of ventriculoperitoneal shunt; however, there is growing evidence that endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) is an alternative. OBJECTIVE: To compare the success rate and morbidity of ETV with CPC and ventriculoperitoneal shunt (VPS) as the primary treatment of hydrocephalus in patients with myelomeningocele. METHODS: A prospective study from January 2016 to February 2019, involving 46 patients with myelomeningocele who developed hydrocephalus after repair in a tertiary hospital in southwestern Nigeria. Biodata and preoperative features of hydrocephalus were documented. ETV + CPC or VPS was done using standard operative techniques. Patients were followed up monthly for 6 mo. RESULTS: There were 23 patients in the ETV + CPC arm and 22 patients in the VPS arm. Morbidities were cerebrospinal fluid leak, 8.3% in the ETV + CPC arm and 4.5% in the VPS arm, wound dehiscence, 13.6% in the VPS arm, none in the ETV + CPC arm. At 6-mo follow-up, success rate for ETV + CPC was 60.9% and 59.1% for VPS, P = .9. CONCLUSION: ETV + CPC had similar success rate with VPS at 6 mo with lower morbidity. ETV + CPC should be considered a viable alternative when treating patients with myelomeningocele and hydrocephalus.

Pediatric brain abscess - etiology, management challenges and outcome in Lagos Nigeria.

BACKGROUND: Brain abscess in children is a neurosurgical emergency with potentially catastrophic outcome despite the advances made in neuroimaging techniques and antibiotic therapy. Symptoms are nonspecific and may vary with the child's age, location, size, numbers and stage of abscess, and the primary source of infection. Treatment is usually with broad-spectrum antibiotics in combination and surgical evacuation in most cases or antibiotics alone in selected cases with clear-cut indications. This study was to document clinical characteristics, etiological factors, and spectrum of bacteriologic agents responsible for pediatric brain abscess in an African city, the challenges and management outcome over the study period. METHODS: This was a retrospective study over an 11-year period involving 89 children who presented with brain abscess. Information of interest was extracted from the medical records of each participant. The results from data analysis were presented in charts and tables. RESULTS: Eighty-nine children aged 0.85-15.7 years (median age of 6.4 years) met the inclusion criteria. The male-to-female ratio was 1.8:1. Headache (80%), fever (78%), and hemiparesis (78%) were the most common symptoms. Brain imaging deployed was CT scan in 56 (63%), MRI in 9 (10%), and transfontanel ultrasound scan in 24 (27%) children. Seventy-one (80%) children had antibiotics with surgical evacuation while 18 (20%) children received only antibiotics. In 19 (27%) children, the culture of the abscess was negative. In 53 (75%) children, Gram-positive aerobic organisms were isolated. A total of 75 patients (84%) had a favorable outcome. CONCLUSION: Pediatric brain abscess still poses significant public health challenge, especially in resource-limited regions. Successful management of brain abscess requires high index of suspicion for early diagnosis, referral, and intervention.

Collaborative International Neurosurgery Education for Africa-The Journey So Far and the Way Forward.

OBJECTIVE: Lack of standard neurosurgical training has long been a major factor limiting the availability of neurosurgical services in most parts of Africa. International collaborative efforts have however, to a large extent, resolved this challenge. METHODS: A review of previous international collaborative programs and educational initiatives in Africa along with their outcomes and accomplishments was conducted. We make a few recommendations on how these programs could be further improved upon toward more productivity and better output with the few available facilities in Africa. RESULTS: Various international collaborative programs focusing on neurosurgery education and training currently exist in East Africa with well-documented advancements in achieving their goals and especially include Neurosurgery Education and Development Foundation, the Weill Cornell Tanzania Neurosurgery project, Duke East Africa Neurosurgery Program, Duke Global Neurosurgery and Neurosciences, and CURE Hydrocephalus Program. In West Africa, they include the Swedish African Neurosurgical Collaboration and the Association of West African Neurosurgeons. CONCLUSIONS: So far, collaborative neurosurgical education and training has been an effective approach in efficiently and progressively increasing capacity in Africa. To further improve the quality of neurosurgical care in Africa in the face of difficult economic circumstances and significant neurosurgical disease burden, implementation of the suggested recommendations will enhance the capacity and sustainability of these existing programs with the few available facilities and equipment and would go a long way in further reducing the burden in Africa.

Cervical Decompression for Myelopathy in a Resource-Poor Region: Initial Experience.

BACKGROUND: The aim of this study was to document the initial experience and challenges of cervical decompression in a resource-poor region. METHODS: Forty-three patients with cervical myelopathy who had surgery were included in the study. Details including evaluations pre- and postoperative (at 6 weeks and 6 months) using the Nurick score were recorded prospectively. Details of surgery were also documented. RESULTS: The mean age at surgery was 58.0 years. There were 37 men and 6 women. Surgeries performed were anterior cervical decompression and fusion (51.2%), cervical laminectomy (32.6%), corpectomy and occipitocervical fixation (2.3% each), and decompression with lateral mass fixation (11.6%). Four patients presented within 3 months of onset of symptoms (early), whereas 39 after 3 months (late). The Nurick grade significantly improved in 41 patients (97.6%) following surgery (P < 0.001). The average Nurick preoperative score was 3.2, and postoperative it was 2.12 and 1.14 at 6 weeks and 6 months, respectively. In the early presentation group, scores improved from an average preoperative of 2.5-0.5 at 6 months, whereas in the late presentation group, score improved from an average of 3.3 preoperative to 1.2 at 6 months postoperative. CONCLUSIONS: Despite the challenges of poverty, late presentation, and lack of basic standard instruments and equipment, patients with cervical myelopathy in the resource-poor setting had outcomes similar to other well-established centers after surgical decompression. We infer that challenges in setting up a spine unit in a resource-poor region can be circumvented safely.

Infantile supratentorial subdural empyema managed by percutaneous aspiration: an outcome study in a Nigerian city.

Subdural empyema (SDE), a common neurosurgical emergency in the developing countries, accounts for 15%-20% of localised paediatric intracranial infections. In regions where modern diagnostic tools are scarce and inaccessible, detection of SDE may be delayed with subsequent poor outcome. Percutaneous subdural aspiration in patients with open anterior fontanel may be the only surgical option in resource-poor regions of the world. This review focuses on the management outcome, including neurological outcome of these children. Clinical charts of children with SDE and treated by percutaneous subdural tap between February 2006 and August 2014 were reviewed. Demographic, clinical, radiological, bacteriological parameters and outcome data were analysed. Forty-five children with a mean age of 10.6 ± 6.2 months (range: 2-17 months) and followed up for a median duration of 16.4 months were included. The most frequent clinical features were enlarged head circumference, fever, focal neurologic deficits and altered level of consciousness. Diagnosis of SDE was confirmed using trans-fontanel ultrasound scan in 32 (71.1%) children, computerised tomography in 12 (26.7%) children and magnetic resonance imaging in one (2.2%) child. SDE was unilateral in 73.3% and bilateral in 26.7%. In 23 (51.1%) children with a positive culture, Staphylococcus aureus (n = 10), anaerobes (n = 7), Escherishia coli and Haemophilus influenza (n = 6 each) were the most common organisms. Forty-three children (95.6%) survived, 36 of which had good Glasgow outcome score. Seven children still had moderate deficits at 3 months. Treatment of SDE in young children with patent fontanel using percutaneous subdural tap has good therapeutic and neurological outcome.

Proposal of modification in management strategy for intracranial hemorrhage in low- and middle-income countries.

This brief communication describes the challenges faced by neurosurgeons in Low- or middle-income countries to treat neurosurgical emergencies from intracranial bleeds (whether traumatic or spontaneous). The authors point out that in low- or middle-income countries and Africa in particular, resources, facilities, and personnel are lacking to follow the guidelines proposed for treating these conditions in high-income countries. The proposal offered here is to move to early surgical intervention because algorithms to monitor patients under conservative management guidelines are often not possible.

Early outcome of combined endoscopic third ventriculostomy and choroid plexus cauterization in childhood hydrocephalus.

OBJECT: Although shunts have been the mainstay in treating hydrocephalus over the past 5 decades, the use of endoscopic techniques in addressing this disorder in children offers both the neurosurgeon and the patient a unique opportunity to avoid shunting and its attendant complications. The combination of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) remains uncommon in most centers despite its potential promise. The authors sought to investigate the efficacy of combining ETV and CPC (ETV+CPC) in treating childhood hydrocephalus in Nigeria. Infection and spina bifida contribute a high percentage of the cases of hydrocephalus in Nigeria. METHODS: Over a 2-year period, all children 0-18 years of age who had endoscopic treatment for hydrocephalus were prospectively evaluated to determine the need for subsequent treatment. Children who had the combination of ETV+CPC were identified as a subcategory and form the basis of this retrospective study. RESULTS: Twenty-two of 38 endoscopically treated children had undergone the combination of ETV+CPC for hydrocephalus of varied etiology. There was a male preponderance (2.5:1), and 90% of the patients were infants. The overall success rate was 75%, with the best outcome in children with spina bifida. One child required a repeat ETV. CONCLUSIONS: The combination of ETV+CPC is useful in treating children with hydrocephalus of varied etiology. The complication profile is acceptable, and the overall success rate is comparable to that associated with shunt insertion.

Infantile subdural empyema: The role of brain sonography and percutaneous subdural tapping in a resource-challenged region.

BACKGROUND: This study explored the outcome of children with patent anterior fontanelles who were treated with trans-fontanelle ultrasound scan (TFUSS), which is more affordable and available than CT scan and MRI in the diagnosis of childhood intracranial pathologies and treatment of subdural empyema, in developing countries. PATIENTS AND METHODS: Seventeen infants with post-meningitic subdural empyema, diagnosed using trans-fontanelle ultrasound alone and treated with subdural tapping over a 31-months period, were studied. RESULTS: Eleven patients presented with grades II and III Bannister and William grading for level of consciousness in intracranial subdural empyema. Aspirate from 7 (41.2%) patients were sterile. The most common organisms isolated were Streptococcus faecalis 3 (17.6%), Haemophilus Influenza 2 (11.8) and Staphylococcus aureus 2 (11.8), multiple organisms were isolated in three of the patients. Ninety-four percent (94%) of the patients had good outcome. Five subjects developed hydrocephalus, one patient had a recurrence of subdural empyema, four patients had residual hemiparesis, two of the four patients had speech difficulties, while one patient (~6%) died. CONCLUSION: While CT and MRI remain the gold standard for investigating intracranial lesions, transfontanelle ultrasonography is adequate for diagnosis of infantile subdural empyema in resource-challenged areas. Percutaneous subdural tap is an affordable and effective therapy in such patients with financial challenges.