Single-Stage Surgical Reconstruction of Posttraumatic Compound Complex Fronto-Basal Cranial Vault Fracture in a Resource-Limited Practice.

BACKGROUND: The extant literature on the surgical treatment of posttraumatic compound, complex frontal basal calvarial skull fracture suggests that this be a staged procedure. There are many socioeconomic constraints in low-resource regions of the world to the feasibility of this standard practice. METHODS: A single-stage operative procedure for the surgical treatment of these fractures in a neurosurgery practice in Nigeria is here annotated. In addition, an observational outcome analysis of this surgical technique in a prospective consecutive cohort of patients over a 6-year period is presented. RESULTS: Fourteen patients, all males, mean age 33.9 years (SD, 6.6) underwent this surgical procedure. Majority were late neurosurgical referrals, hence median time to surgery was 96 hours (range, 48-2160). Twelve patients (85.7%) had history of loss of consciousness, median duration of 34 hours; 7 (50%) had associated brain contusions; 6 (43%) significant pneumocephalus; and acute extradural and subdural haematoma in 4 and 2 patients respectively. The surgery was successful in all; 13 (93%) had normal outcome on the Glasgow outcome scale at hospital discharge; 12 have been followed up for 1 to 72 months, median 33. Seven of these were for 30 months or more. There was no patient of surgical site infection in the perioperative or the follow-up period to date. The aesthetic outcome was also acceptable. CONCLUSION: The pragmatic surgical technique herein annotated appears clinically and aesthetically effectual in the operative treatment of compound, complex frontal basal cranial vault fracture.

A Prospective Study on the Causes of Delayed Diagnosis of Childhood Cancer in Ibadan, Nigeria.

Outcome in cancer may be improved by early diagnosis and prompt treatment. The objectives of this study were to determine the prediagnostic intervals (lag time) in childhood cancer and the factors that influence them at the University College Hospital (UCH), Ibadan. The study was prospective and observational and involved children diagnosed with cancer from July 2012 to June 2014 at UCH, Ibadan, Nigeria. A history of the illness was obtained and physical examination performed on each patient. Information obtained and analyzed included sociodemographic data, cancer diagnosis and stage, time intervals between onset of symptoms and diagnosis, and the reasons for delayed diagnosis. A total of 91 children were studied, comprising 46 males and 45 females. Their ages ranged from 1 month to 15.0 years, with a median of 4.0 years. Median parent lag time was 2.0 weeks, median health system or physician lag time 8.0 weeks, and median overall lag time 15.5 weeks. Overall lag time had a negative correlation with age of child at diagnosis, a positive correlation with the number of health facilities visited before diagnosis, and was shorter in mothers younger than 40 years of age. Lag time was significantly different among the diagnostic tumor categories, with Burkitt lymphoma having short times and retinoblastoma with long times. Delayed diagnosis of childhood cancer is a significant problem in Ibadan. Education of parents and health workers on early presentation and accurate diagnosis are recommended.

Outcome of Nonoperative Management of Selected Cases of Acute Traumatic Intracranial Hematomas in a Rural Neurosurgical Service of a Developing Country.

OBJECTIVE: In resource-limited settings, the standard of care prescribed in developed countries for either operative or nonoperative management of traumatic intracranial hematomas (TICHs) frequently has to be adapted to the economic and infrastructural realities. This study aims to present the outcome of selected cases of TICHs managed nonoperatively without routine intensive care unit admission, repeated cranial computed tomography (CT) scan or intracranial pressure monitoring at a rural neurosurgical service in a developing country. METHODS: This was a retrospective analysis of a cohort of our patients with cranial CT-confirmed TICHs selected for nonoperative treatment from our prospective head injury (HI) register over a 42-month period. RESULTS: There were 67 patients (51 males) in this study with a mean age of 38.6 (standard deviation, 17.6) years, having mild HI in >half, (55.2%, 37/67) and anisocoria in 22.4% (15/67). Road traffic accident was the most common (50/67, 74.7%) trauma etiology. Isolated acute-subdural hematoma, intracerebral hemorrhage, and epidural hematoma occurred in 29.9%, 25.4%, and 22.4% of the patients respectively. Only 2 of 8 patients in whom intensive care unit admission was deemed necessary could afford admission. Repeat cranial CT scan was requested in 8 patients (8/67, 11.9%); only 5 of these could afford the investigation. The outcome of care was good in 82.1% patients (55/67). Increasing severity of the HI (P < 0.01) and presence of pupillary abnormality (P = 0.03) were significant predictors of poor outcome. CONCLUSIONS: In a Nigerian rural neurosurgery practice, nonoperative management of a well-selected cohort of TICHs was attended by acceptable level of favorable outcome.

Prevention of myelomeningocele: African perspectives.

BACKGROUND: The prevention of neural tube defects (NTDs) is now an issue of major public health concern. Myelomeningocele, the most common NTD, often results in severe disabilities and may be life threatening. In Africa, there is little awareness of the NTDs, and most African countries lag behind in the global efforts at preventing them. PURPOSE: Following a review of global literature, we discuss the burden of myelomeningocele on the society and the current state of its prevention with an emphasis on Africa within the global context. The realization that folate supplementation reduces the occurrence of NTDs by as much as 85 % offers an opportunity to promote global reduction in the incidence of NTDs through (1) effective folate supplementation strategies combined with (2) secondary prevention using prenatal detection and termination of NTD pregnancies within respective national legal frameworks. We call attention to the poor state of understanding of NTDs in Africa and the alarming rarity of policies to prevent the condition in the continent. CONCLUSIONS: The understanding of the contributions of folate deficiency to the causation of NTDs has enabled appropriate, though still inadequate, preventive measures to be taken in several countries. We call on African governments and the international community to rapidly promote policies aimed at making fortification of wheat (and or other substitute staple foods) with folic acid universally available.

Traumatic Spinal Cord Injury in Children: Clinical Profile and Management Outcome in a Developing Country's Rural Neurosurgery Practice.

BACKGROUND: There is paucity of data-driven study on pediatric traumatic spinal cord injury (SCI) in the developing countries. This study aims to define the clinical profile of pediatric traumatic SCI in a rural tertiary hospital in a sub-Saharan African country. METHODS: This was a prospective observational study of all children with spinal cord injury managed at our center over a 42-month period. RESULTS: There were 20 patients, comprising 13 males and 7 females with a mean age of 11.5 years. Road traffic crash was the cause in 70% of the cases (motorcycle accident = 45%), and fall from height in 25%. Pedestrians were the victims of the road traffic crash in 42.9% (6/14) of the cases, while 21.4% (3/14) and 28.6% (4/14) were passengers on motorcycles and in motor vehicles, respectively. The cervical spine was the most common location of injury, occurring in 90% of the cases (18/20). Seventy-five percent of the patients (15/20) had transient deficits, but were grossly normal neurologically on examination (American Spinal Cord Injury Association [ASIA] grade E); 2 patients had ASIA D, while 1 patient each had ASIA C, B, and A injuries. All patients were managed nonoperatively. The patients with incomplete deficits improved, while those with complete injury did not make any motor or sensory gain. CONCLUSION: Road traffic accident, mostly motorcycle crash, was the most common etiology of pediatric SCI in this series, and most of the injuries were located in the cervical spine. Disabling injury constituted a small proportion of pediatric SCI in our practice.

Awake Craniotomy in Africa: A Scoping Review of Literature and Proposed Solutions to Tackle Challenges.

BACKGROUND: Awake craniotomy (AC) is a common neurosurgical procedure for the resection of lesions in eloquent brain areas, which has the advantage of avoiding general anesthesia to reduce associated complications and costs. A significant resource limitation in low- and middle-income countries constrains the usage of AC. OBJECTIVE: To review the published literature on AC in African countries, identify challenges, and propose pragmatic solutions by practicing neurosurgeons in Africa. METHODS: We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review guidelines across 3 databases (PubMed, Scopus, and Web of Science). English articles investigating AC in Africa were included. RESULTS: Nineteen studies consisting of 396 patients were included. Egypt was the most represented country with 8 studies (42.1%), followed by Nigeria with 6 records (31.6%). Glioma was the most common lesion type, corresponding to 120 of 396 patients (30.3%), followed by epilepsy in 71 patients (17.9%). Awake-awake-awake was the most common protocol used in 7 studies (36.8%). Sixteen studies (84.2%) contained adult patients. The youngest reported AC patient was 11 years old, whereas the oldest one was 92. Nine studies (47.4%) reported infrastructure limitations for performing AC, including the lack of funding, intraoperative monitoring equipment, imaging, medications, and limited human resources. CONCLUSION: Despite many constraints, AC is being safely performed in low-resource settings. International collaborations among centers are a move forward, but adequate resources and management are essential to make AC an accessible procedure in many more African neurosurgical centers.

Post-operative day two versus day seven mobilization after burr-hole drainage of subacute and chronic subdural haematoma in Nigerians.

INTRODUCTION: The traditional care of patients with subacute/chronic subdural haematoma (S/CSDH) often involves delayed mobilization after burr-hole drainage. It is thought that delayed mobilization aids brain re-expansion thereby reducing the risk of recurrence. However, there is paucity of information regarding its efficacy and safety over early mobilization. We evaluated the efficacy and complications of each type of mobilization following burr-hole drainage of S/CSDH. METHOD: This was a prospective study from October 2004 and September 2010. A total of 50 patients who had burr-hole drainage of S/CSDH were sequentially allocated to either early (day 2) or late (day 7) mobilization (EM or LM) groups (25 patients in each group). Wound related complications, recurrence of haematoma, complications of prolonged bed rest and Glasgow Outcome Score (GOS) at discharge were studied in the two groups. Patients who could not obey commands to mobilize in the early post-operative period were excluded. RESULTS: There were 43 (86%) males and 7 (14%) females. The mean age was 57 years (range: 27-90 years). Fourteen (28%) of the patients were elderly (age > 65 years). Two complications, wound infection in a 76-year old man in the LM group and tension pneumocephalus requiring re-opening burr-hole drainage in a 55-year old man in the EM group were recorded. There was no recurrence or problem associated with prolonged bed rest in the two groups. Five (10%) patients had moderate disability (GOS 4) at discharge (1 EM, 4 LM) while the others (90%) had good recovery (GOS 5) (24 EM, 21 LM). These differences were not statistically significant (p-value: 0.349). CONCLUSION: It appears that both EM and LM are equally beneficial in the post-operative care of patients following burr-hole drainage of S/CSDH. There is no significant complication referable to the specific type of mobilization. The authors, therefore, advocate EM of patients to reduce the length of hospital stay.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study.

BACKGROUND: Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. METHODS: We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. FINDINGS: Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49). INTERPRETATION: Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. FUNDING: National Institute for Health Research Global Health Research Group.

Mannitol Dosing Error during Pre-neurosurgical Care of Head Injury: A Neurosurgical In-Hospital Survey from Ibadan, Nigeria.

Objectives Inappropriate use of mannitol is a medical error seen frequently in pre-neurosurgical head injury (HI) care that may result in serious adverse effects. This study explored this medical error amongst HI patients in a Nigerian neurosurgery unit. Methods We performed a cross-sectional analysis of a prospective cohort of HI patients who were administered mannitol by their initial non-neurosurgical health care givers before referral to our center over a 22-month period. Statistical Analysis A statistical software was used for the analysis with which an α value of <0.05 was deemed clinically significant. Results Seventy-one patients were recruited: 17 (23.9%) from private hospitals, 13 (18.3%) from primary health facilities (PHFs), 20 (28.2%) from secondary health facilities (SHFs), and 21 (29.6%) from tertiary health facilities (THFs). Thirteen patients (18.3%) had mild HI; 29 (40.8%) each had moderate and severe HI, respectively. Pupillary abnormalities were documented in five patients (7.04%) with severe HI and neurological deterioration in two with mild HI. Mannitol administration was deemed appropriate in only 43.7% (31/71). Data on mannitol dosing in 60.6% (43/71) of the patients showed 8/43 (18.6%) receiving continuous 10% mannitol infusion. The remaining 35/43 received mannitol as a 20% solution but also showing dosing error in 62.9% (22/35): overdosing in 7/35 (20%), and nonbolus administration in 15/35 (42.9%). The distribution of the dosing error among the referring health facilities (all the 13 [100%] patients from private hospitals, 66.7% from PHF, 60% from SHF, and 45.5% from THF) showed a trend of better performance ( p = 0.002) by the THFs. Conclusion Mannitol use is apparently fraught with an understudied medical error in the pre-neurosurgical care of the head injured.

Central nervous system congenital malformations in a developing country: issues and challenges against their prevention.

BACKGROUND: Little efforts are geared towards prevention of CNS anomalies in the developing countries. METHODS: A 1-year prospective cross-sectional analysis of the cases of CNS congenital anomalies seen in a Nigerian neurosurgical unit. This included both the children's and parents' sociodemographics, the profiles of the CNS anomalies, and the maternal obstetric health behaviors toward primary and/or secondary prevention of the anomalies. Statistical analysis was done with the Pearson's chi-square (or Fishers' exact) test. Level of significance set at P < 0.05. RESULTS: There were 54 cases of cranial and spinal gross CNS anomalies, including 32 neural tube defects; two thirds of the parents were low-income earners, and half had only basic education. Thirty percent of the pregnancies were unbooked; the mean gestational age (GA) at booking and commencement of obstetric micronutrient supplementation was 4.6 months. No case had periconceptional folic acid supplementation. Obstetric ultrasonography was performed late in pregnancy (mean GA 6 months), made positive diagnosis of CNS anomaly in only 14%, and was performed mainly in unsupervised private clinic settings in 98%. CONCLUSIONS: Little or no attention is currently paid to the prevention of CNS congenital anomalies in much of the low- and middle-income countries of the world. There is a great need to regulate the practice of obstetric ultrasonography in Nigeria. There is even a much greater, more fiercely urgent need to ensure periconceptional folic acid supplementation for all women of childbearing age through appropriate food fortification in these societies.

Basilar skull fracture: outcome of acute care without antibiotic prophylaxis in a Nigerian neurosurgical unit.

AIM: A prospective observational study of the in-hospital outcome of the management of BSF without antibiotic prophylaxis in a Nigerian neurosurgical unit. MATERIAL AND METHODS: All cases of HI with clinical diagnosis of BSF over an 8-month period were reviewed. Their demographic, clinical, and in-hospital outcome parameters were analysed. We also compared some clinical and outcome characteristics between this study group and a contemporary cohort of patients in our unit with Head Injury but without CSF leak RESULTS: There were 47 cases. The CSF leak was from the nostrils in 18 (38.3%), the ears in 16 (34.04%), and both ears and nostrils in 12 (25.53%). The cause of injury was road accidents in 91%, and the severity of the Head Injury was mild, moderate and severe respectively in 42.55, 25.53 and 31.91%. Meningitis occurred in 2 patients (4.25%); in-hospital outcome was good in 68.1% and poor in 31.9% and this was significantly (p < 0.05) affected primarily by the severity of the brain injuries. These in-hospital outcome rates and their determinants were similar to those in our unit's contemporary cohort of Head Injury without BSF. CONCLUSION: Management of traumatic BSF without antibiotic prophylaxis in a developing country setting has not been accompanied with an increased rate of unfavourable outcome.

Determinants of discharge against medical advice from a rural neurosurgical service in a developing country: A prospective observational study.

BACKGROUND: In low-resource regions of the world, discharge against medical advice (DAMA) is one empiric contributory factor to poor in-hospital outcome that is not often mentioned. This study aims to investigate the determinants of DAMA from a rural neurosurgical service in a developing country. METHODS: This was a prospective observational study of all patients who discharged against medical advice in our service between November 2018 and October 2019. RESULTS: There were 88 patients, 67 (76.1%) males, in the study, (M:F = 3.2:1), representing 17.4% of our patient population in the study period. The peak incidence was in the 20-29 years age group which accounted for 37.5% of the cases. About 55% of the patients presented directly to our center; 31.8% were referred from other hospitals, while 3.4% came from traditional caregivers and 1.1% from religious homes. Head injury was the most common indication for presentation (76.1% of the cases). The duration of hospital stay ranged from 2 h to 14 days. Majority of the patients (87.5%) left the hospital within 8 h of presentation. The reason for DAMA was financial constraints in 50% of cases, inadequate health literacy in 20.5%, financial constraints and poor health literacy together in 12.5%, religious misgivings in 4.5%, and traditional belief in 2.3%. Neurotrauma was predictive of early DAMA (P = 0.001). CONCLUSION: The rate of DAMA was high in our study. Financial constraints with other socioeconomic limitations were the most common causes of DAMA in our environment.

Rapid growth of primary cerebral fibrosarcoma with conversion to glioblastoma at second recurrence.

We present a case of de novo fibrosarcoma in a 43-year-old male, with MRI documented evolution from a 5 mm hyperintense area to 5 cm tumor mass in a 12-month period. The diagnosis of low-grade fibrosarcoma was established by three experienced neuropathologists. The patient underwent gross total resection with adjuvant fractionated conformal radiotherapy. Following first recurrence 3 months later, the patient was reoperated and stereotactic radiosurgery of a residual tumor was performed thereafter. The pathological diagnosis was similar, but with additional extensive radiation effects. Six months later the patient underwent aggressive surgical resection for second recurrence. The pathological diagnosis was WHO grade IV glioblastoma. The etiology of this highly unusual progression from primary mesenchymal neoplasm to high-grade glioma is discussed.

Helmet usage in motorcycle-related neurotrauma.

Motorcycles provide important means of transportation for humans and goods especially in developing economies. The authors observe that Murphy and his colleagues aptly illustrate the burden of motorcycles on national healthcare systems but did not present clear data relating to the effect of helmet use in reducing the severity of head injury by motorcyclists, as well as supportive data for the promotion of Ireland's SHARP guidelines. Controlled studies to assess the effectiveness of different helmets are advocated.

Outcome of Cerebral Metastasectomy in Select Cases of Brain Metastases from Breast Cancer in Ibadan, Nigeria.

BACKGROUND: Brain metastasis (BM) from breast cancer is increasingly encountered clinically because of the continuing success in the oncological control of the primary disease. Data-driven reports on the surgical treatment of BM from breast cancer are sparse in sub-Saharan Africa. METHODS: This is a prospective cohort study of the outcome of surgical excision of BM from breast cancer in an academic surgical practice in Ibadan, Nigeria. RESULTS: A total of 12 consecutive cerebral metastasectomies, all in females with primary breast cancer, were recorded over the study period. The median age (range) at breast cancer diagnosis was 41 (27-72) years, and the time interval from primary disease to BM was 19 (12-29) months. The BM was the first site of systemic disease progression in all, and was heralded by headache, seizures, and hemiparesis in more than two-thirds of the patients. The brain lesions were multiple in a quarter: >4 cm large in 42% and were located supratentorial in >80%. They all achieved good recovery and in-hospital outcome after surgical lesionectomy-infra- and supratentorial craniotomies-but only two-thirds could access postsurgical adjuvant whole brain radiation therapy. Median survival after cerebral metastasectomy was 18 (11-55) months, and more than a quarter were alive for ≥3years. These survival statistics were significantly better than those of a contemporary cohort of our patients with breast cancer who also had BMs that were not surgically treated for various clinical and logistic limitations. CONCLUSIONS: Surgical resection is feasible for BM from breast cancer even in low-resource clinical practice. It has a salutary effect on the patients' quality of life.

Cranioplasty Following Decompressive Craniectomy.

Cranioplasty (CP) after decompressive craniectomy (DC) for trauma is a neurosurgical procedure that aims to restore esthesis, improve cerebrospinal fluid (CSF) dynamics, and provide cerebral protection. In turn, this can facilitate neurological rehabilitation and potentially enhance neurological recovery. However, CP can be associated with significant morbidity. Multiple aspects of CP must be considered to optimize its outcomes. Those aspects range from the intricacies of the surgical dissection/reconstruction during the procedure of CP, the types of materials used for the reconstruction, as well as the timing of the CP in relation to the DC. This article is a narrative mini-review that discusses the current evidence base and suggests that no consensus has been reached about several issues, such as an agreement on the best material for use in CP, the appropriate timing of CP after DC, and the optimal management of hydrocephalus in patients who need cranial reconstruction. Moreover, the protocol-driven standards of care for traumatic brain injury (TBI) patients in high-resource settings are virtually out of reach for low-income countries, including those pertaining to CP. Thus, there is a need to design appropriate prospective studies to provide context-specific solid recommendations regarding this topic.

Clinical outcome of closed reduction of cervical spine injuries in a cohort of Nigerians.

Study design: A prospective observational study. Objectives: To evaluate the effectiveness of closed reduction of cervical spine injuries (CSIs) using cervical traction and identify probable complications. Setting: Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria. Methods: Consecutive CSIs managed by closed reduction using Gardener-Well's Tongs traction were prospectively analysed. The data included imaging and neurological examinations findings, Frankel grading, and extent of reduction. Reduction of 95% or more was deemed satisfactory. The primary outcome measures were extent/degree of reduction and neurologic status classified as improved, same, or worse. Other complications were taken as secondary outcome measures. Result: Seventy-four patients, 49 males, mean age 35.2 years (SD 9.7) were included. In all, 78.4% presented within 72 hours of injury. In total, 85.1% had road traffic crashes. Anterior subluxation was seen in 86.5%. The degree of displacement was <25% in 36/74 (48.6%), 25-50% in 19/74 (25.7%), 50-75% in 8/74 (10.8%), and >75% in 11/74 (14.9%). Traction reduction was done after 7 days of injury in 52.7% and same day of injury in 1.4%. Reduction weight ranged from 2 kg to 60 kg. Reduction was satisfactory in 67.6% and failed in 32.4%. In all, 81.1% of patients remained neurologically the same, while 18.9% improved. Causes of failed reduction were facet lock (15), old injury (8), new-onset/worsening pain (3), and over-distraction (2). Complications of closed reduction were over-distraction (5), tong pull-out (2), new-onset/worsening pain (2), and skull perforation (1). Conclusions: Satisfactory closed reduction is feasible in patients with CSI and significant malalignment. The method is associated with few complications.

Nonshaved cranial surgery in black Africans: a short-term prospective preliminary study.

BACKGROUND: Many studies on white populations have shown the absence of any scientific, or even beneficial, basis for the traditional preoperative ritual of shaving the operative field. We were not able to lay our hands on any document regarding this subject on any black African population. METHODS: We prospectively performed 17 cranial procedures in nonshaved fields in 15 selected black Africans in the Lagos State University Teaching Hospital, Ikeja, Nigeria. RESULTS: There was no serious complication recorded over a short-term follow-up of 2 to 6 months. The short, curly, crimpy, and densely knotted black African scalp hairs however did pose some unique perioperative challenges to us. CONCLUSIONS: Nonshaved cranial surgery, as in whites/Asians, can also be safely carried out in black Africans. This however demands some attention to details in the perioperative care of the incision sites. We found this caveat to be particularly more imperative in black Africans because of their unique anthropological scalp hair characteristics.

Determinants of Timing of Presentation of Neurotrauma Patients to a Neurosurgical Center in a Developing Country.

BACKGROUND: A major goal in neurotrauma management is the prevention of secondary neuronal injuries. This goal is time bound as neurological deficits once established are usually irreversible. Late presentation is the norm in most neurotrauma patients in developing countries. AIMS: The aim of the study was to review the timing of presentation of neurotrauma patients and the possible causes of their late presentation for neurosurgical care in our practice. METHODS: A cross-sectional study of a 4-month prospective database of neurotrauma patients presenting to the University College Hospital, Ibadan, was done. The participants' biodata, injury characteristics, initial-care details before referral, and information on timing and causes of delay were analyzed. RESULTS: The study subjects included 111 patients, 80.2% (89/111) were males, and 52.8% aged 21-40 years. Head injury (HI), spinal cord injury (SCI), and combined HI and SCI occurred, respectively, in 80.2%, 14.4%, and 5.4%. Road accidents followed by falls were seen in 73.9% and 14.4% (16), respectively. Just 46.8% (52/111) cases presented within 12 h of injury and only 37 (33.3%) within 4 h. Majority, 83.8% (93/111) were referrals from primary care. These referrals were delayed in 81.7% (76/93) of these. The referring health facilities were located intracity with our center in 54%. Other causes of delayed presentation of these study participants included long-distance travel to our center, lack of funds, or a combination of the above factors. Eighty-nine patients (80.2%) were brought in by family members and the remaining minority by passers-by and road safety personnel. CONCLUSIONS: Delayed referral from primary care features prominently in timing of presentation of neurotrauma patients in Nigeria. There is a need for collaboration as well as continuing medical education between the neurotrauma specialists and primary care physicians.

Titanium Clamps for a Simple Low-Profile Autologous Osteosynthesis in the Reconstruction of Posttraumatic Craniofacial Convexital Skeletal Disruption.

Attempts at reconstruction of posttraumatic craniofacial defects (PTCDs) can be a challenge in low-resource practice areas of the world where the needed biomaterials are logistically beyond reach. A simple low-profile technique of autologous osteosynthesis for PTCD using the titanium clamps is presented in this report. In addition, a 6-year prospective database on a consecutive cohort of patients who underwent this procedure was analyzed for clinical, functional, and aesthetic outcomes, both in-hospital and at midterm follow-up. The clinical data of 18 patients, all males, mean age 31.3 years (standard deviation, 9.7), were analyzed. Road traffic accidents (RTAs) were the cause of trauma in 14 of 18 patients (78%) and motorcycle crash, none helmeted, in 10 of the 18 patients (71% of RTAs). Out of 18 cases, 17 were open fractures; 89% suffered mild head injury, and associated brain injury on CT scan included pneumocephalus in 6 (5 of them significant); acute extradural hematoma in 4 and subdural in 2, and brain contusions in 9. The surgery was successful in all the cases: operative time <3 hours in 10 cases (56%), the in-hospital outcome was good in 95%. The median follow-up time was 24 months, in 6 of the 18 cases for ≥36 months. There was no case of surgical site infection in the perioperative or the follow-up period to date. The aesthetic outcome was also acceptable. This surgical technique for the reconstruction of PTCD appears effectual. Although its low cost makes it very attractive therein, it appears to be actually also recommendable even outside the low-resource developing countries.