Surgical decompression for traumatic spinal cord injury in a tertiary center.

BACKGROUND: There are controversies regarding the importance and timing of spinal cord decompression following trauma. Documented evidence shows that early decompression in the setting of acute spinal cord injury (SCI) improves neurologic outcomes. Our objective was to evaluate the outcome of posttraumatic spinal cord decompression with or without spinal stabilization in our region. METHODOLOGY: We performed a cross-sectional study on adult patients who presented with acute spinal cord compression of traumatic etiology within a 2-year period. The primary outcome was change in Frankel's grading 6 months after surgery. Secondary outcomes were complication rates and mortality. RESULTS: A total of 35 patients made up of 24 (68.6%) males and 11 (31.4%) females were recruited into the study. The spectrum of injuries included cervical 27 (77.1%), thoracic 7 (20.0%), and lumbar vertebrae 1 (2.9%). The outcome as measured by Frankel's grade at 6 months after surgery showed improvement in 9 (25.7%) patients following intervention. All patients who presented with Frankel's Grade C and D improved to Grade E while none of those who presented with Frankel's Grade E deteriorated. The common complications of spine decompression and fixation in this series were surgical site infections (11.4%) and chest infections (11.4%), especially in high cervical injury. CONCLUSION: Spinal cord decompression with spinal stabilization enhances the rehabilitation of patients with unstable spine and completes spinal cord injuries. Our experience shows improvement in neurological function in patients with spinal cord decompression despite the challenges of instrumentation in Sub-Saharan Africa.

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.

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.

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.