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

Academic Neurosurgery in Nigeria- Past, Present, and Future: A Review

Nigeria's neurosurgical field faces profound challenges, including a critically low neurosurgeon-to-patient ratio and significant migration of medical professionals to developed countries. High costs, low socioeconomic status, and the urban-centric location of neurosurgical centers impede access to care. Key barriers to service delivery include lack of manpower, insufficient emergency care, limited imaging modalities, inadequate operative equipment, and ineffective political and administrative policies. Neurotrauma is the primary reason for neurosurgical intervention but is poorly managed due to delayed access and insufficient guidelines. The neurosurgical education system is strained by limited training capacity and the absence of subspecializations, restricting specialized care. Research output is low, hindered by limited infrastructure, lack of databases, insufficient funding, and minimal international collaboration. To address these issues, it is critical to enhance the imaging capabilities, ensure the availability of operative equipment, and establish effective policies for task sharing and communication at different levels of care. Other approaches include expanding training capacity, particularly in rural areas, implementing a uniform match system for residency, addressing gender disparities, and utilizing dual practice to ensure adequate compensation for neurosurgeons. Furthermore, stakeholders should develop subspecialization programs in areas such as neurovascular, neuro-oncology, pediatric neurosurgery, and minimally invasive neurosurgery to expand service scope. To transform the neurosurgical research landscape, efforts should be made to establish electronic medical databases, foster international collaborations to ensure funding, and make research mandatory for accreditation renewal to ensure continuous academic contribution.

Epidemiological Burden of Neurotrauma in Nigeria: A Systematic Review and Pooled Analysis of 45,763 Patients

OBJECTIVE

Neurotrauma is a significant cause of morbidity and mortality in Nigeria. We conducted this systematic review to generate nationally generalizable reference data for the country.

METHODS

Four research databases and gray literature sources were electronically searched. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions and Cochrane's risk of bias tools. Descriptive analysis, narrative synthesis, and statistical analysis (via paired t-tests and χ2 independence tests) were performed on relevant article metrics (α = 0.05).

RESULTS

We identified a cohort of 45,763 patients from 254 articles. The overall risk of bias was moderate to high. Most articles employed retrospective cohort study designs (37.4%) and were published during the last 2 decades (81.89%). The cohort's average age was 32.5 years (standard deviation, 20.2) with a gender split of ∼3 males per female. Almost 90% of subjects were diagnosed with traumatic brain injury, with road traffic accidents (68.6%) being the greatest cause. Altered consciousness (48.4%) was the most commonly reported clinical feature. Computed tomography (53.5%) was the most commonly used imaging modality, with skull (25.7%) and vertebral fracture (14.1%) being the most common radiological findings for traumatic brain injury and traumatic spinal injury, respectively. Two-thirds of patients were treated nonoperatively. Outcomes were favorable in 63.7% of traumatic brain injury patients, but in only 20.9% of traumatic spinal injury patients. Pressure sores, infection, and motor deficits were the most commonly reported complications in the latter.

CONCLUSIONS

This systematic review and pooled analysis demonstrate the significant burden of neurotrauma across Nigeria.

Variations in the Neurosurgical Management of Depressed Skull Fractures in Adults: An International Cross-Sectional Survey

BACKGROUND

 Depressed skull fractures have been well described since antiquity, yet its management remains controversial. Contentious issues include the use of prophylactic antibiotics and antiepileptics, the role of nonoperative management, and the replacement/removal of bone fragments. Our objective was to explore the management patterns of closed and open depressed skull fractures across the world.

METHODS

 A 23-item, web-based survey was distributed electronically to the members of national neurosurgical associations, and on social media platforms. The survey was open for data collection from December 2020 to April 2021.

RESULTS

 A total of 218 respondents completed the survey, representing 56 countries.With regard to open fractures, most respondents (85.8%) treated less than 50 cases annually. Most respondents (79.4%) offered prophylactic antibiotics to all patients with open fractures, with significant geographical variation (p < 0.001). Less than half of the respondents (48.2%) offered prophylactic antiepileptics. Almost all respondents (>90%) reported the following indications as important for surgical management: (1) grossly contaminated wound, (2) dural penetration, (3) depth of depression, and (4) underlying contusion/hematoma with mass effect. Most respondents treated less than 50 cases of closed depressed skull fractures annually. Most European respondents (81.7%) did not offer prophylactic antiepileptics in comparison to most Asian respondents (52.7%; p < 0.001). Depth of depression, an underlying hematoma/contusion with mass effect, and dural penetration were the most important surgical indications.

CONCLUSIONS

 There remains a great degree of uncertainty in the management strategies employed across the world in treating depressed fractures, and future work should involve multinational randomized trials.

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.

Can we build better? Challenges with geospatial and financial accessibility in the Caribbean. Illustrative case

BACKGROUND

Within the Caribbean, Curaçao provides a neurosurgical hub to other Dutch Caribbean islands. At times, the inefficiency of neurosurgical referrals leads to unsatisfactory patient outcomes in true emergency cases.

OBSERVATIONS

This article reports an illustrative case of a patient in need of emergency neurosurgical care, who was referred to a tertiary health institution in Curaçao. This case highlights the challenges of timely neurosurgical referrals within the Dutch Caribbean.

LESSONS

Highlighting this case may provide a foundation for further discussions that may improve neurosurgical care and access. Limiting long-distance surgical referrals in the acute care setting will aid in saving lives.

Utilizing indocyanine green video angiography to bridge intracranial aneurysm treatment gaps in low- and middle-income countries: a mini-review

Intracranial aneurysms, affecting 2%-5% of the population, pose a significant challenge to neurosurgeons due to their potential to cause subarachnoid haemorrhage and high mortality rates. Intraoperative angiography is necessary for effective surgical planning and indocyanine green video angiography (ICG-VA) has emerged as a useful tool for real-time visualization of aneurysmal blood flow, aiding in better planning for potential blood flow and detection of aneurysm remnants. This mini narrative review explores the application of ICG-VA in intracranial aneurysm surgery. Compared with conventional dye-based angiography, ICG-VA is safer, more effective and more cost-effective. It can assess haemodynamic parameters, cerebral flow during temporary artery occlusion, completeness of clipping and patency of branch vessels. However, implementing ICG-VA in low- and middle-income countries presents challenges such as financial constraints, limited access to training and expertise, patient selection and consent issues. Addressing these obstacles requires capacity-building, training programmes for neurosurgeons and multidisciplinary teams, technology transfer, equipment donations, public-private partnerships, continued research and development, reducing conventional dye usage, reducing ICG wastage, exploring mechanisms to reuse ICG dyes and advocating for increased government funding and healthcare budgets.

Efficacy of 48 hours dose of phenytoin in prevention of early post-traumatic seizure

Background

Antiseizure medications, such as phenytoin sodium, have been shown in some reports to reduce the incidence of early post-traumatic seizure. These medications, however, are not without side effects which may be dose related or duration related. The risks associated with short-term therapy are minimal and often dose related (and hence avoidable). This study intends to determine the efficacy of a short-course (48-hour dose) of phenytoin in prevention of early post-traumatic seizure.

Methods

This was a prospective randomised double-blind clinical intervention study. Head injured patients presenting within the first 24 hours were randomly assigned to either 48-hour dose of phenytoin or control groups, and were observed for clinical seizure over a week. The difference in the incidences of early post-traumatic seizure between the two groups was determined by χ² test. A p<0.05 was considered as statistically significant.

Results

A total of 94 patients were included in the study, 47 each in the control group and the phenytoin group. There were 77 males and 17 female (M:F 4.5:1). Both groups had similar demographic and clinical profile. The incidence of seizure was 21.3% in the control but 2.1% in the treatment arm (p<0.01). All seizures occurred within 24 hours of trauma in the control, while the only episode of seizure in the treatment group occurred later.

Conclusion

A short-course (48-hour dose) of phenytoin might be an effective prophylactic treatment to reduce the incidence of early post-traumatic seizure.

Neurotrauma: a burgeoning, yet understudied disease of rural areas in developing countries

OBJECTIVE

There is a paucity of data-driven reports on neurotrauma from the rural areas of developing countries, despite a disproportionally higher and burgeoning disease burden from those areas. This study aims to define the burden of neurotrauma in a new rural neurosurgical practice of a developing sub-Saharan country in Africa (Nigeria).

METHODS

The authors conducted a prospective observational study of all neurotrauma patients managed at their center over a 36-month period beginning in August 2018.

RESULTS

There were 1067 patients, 816 (76.5%) of them male, accounting for 79% of all the neurosurgical patients seen at the authors' center during the study period. The peak incidence of neurotrauma was in the 20- to 29-year age group. The median trauma duration was 9 hours before presentation. The neurotrauma involved only head injury (HI) in 78% of the patients and only the spine in 4%. HIs were predominantly mild in severity (79%). Spinal cord injuries were largely incomplete (86%) and cervical in location (72%). Road traffic accidents caused approximately 79% (845/1067) of this neurotrauma burden, mostly from motorcycle crashes (69%, 581/845). Fifty-three patients (5%) were managed surgically. The median time from trauma to surgery for the operated patients was 82 hours. Treatment outcome was good in 81.2% of the patients.

CONCLUSIONS

Neurotrauma, mostly caused by motorcycle crashes and other road accidents, accounts for the bulk of the neurosurgical workload in this rural neurosurgical center. Although late presentation and delayed surgical interventions were prominent features of this level of care, the in-hospital outcome was fortuitously good in the majority of patients.

Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Trauma Causes, Injury Types, and Clinical Presentation

BACKGROUND

Traumatic brain injury (TBI) is a public health problem in Ethiopia. More knowledge about the epidemiology and neurosurgical management of TBI patients is needed to identify possible focus areas for quality improvement and preventive efforts.

METHODS

This prospective cross-sectional study (2012-2016) was performed at the 4 teaching hospitals in Addis Ababa, Ethiopia. All surgically treated TBI patients were included, and data on clinical presentation, injury types, and trauma causes were collected.

RESULTS

We included 1087 patients (mean age 29 years; 8.7% females; 17.1% <18 years old). Only 15.5% of TBIs were classified as severe (Glasgow Coma Scale score 3-8). Depressed skull fracture (44.9%) and epidural hematoma (39%) were the most frequent injuries. Very few patients had polytrauma (3.1%). Assault was the most common injury mechanism (69.9%) followed by road traffic accidents (15.8%) and falls (8.1%). More than 80% of patients came from within 200 km of the hospitals, but the median time to admission was 24 hours. Most assault victims (80.4%) were injured >50 km from the hospitals, whereas 46% of road traffic accident victims came from the urban area. Delayed admission was associated with higher Glasgow Coma Scale scores and nonsevere TBI (P < 0.01).

CONCLUSIONS

The injury panorama, delayed admission, and small number of operations performed for severe TBI are linked to a substantial patient selection bias both before and after hospital admission. Our results also suggest that there should be a geographical framework for tailored guidelines, preventive efforts, and development of prehospital and hospital services.

Cohesion Between Research Literature and Health System Level Efforts to Address Global Neurosurgical Inequity: A Scoping Review

BACKGROUND

Research output on global neurosurgery (GNS) has exponentially increased in recent years. As research efforts increase, we must first analyze how the current body of GNS literature fits into the macroscopic schema of systems-based policies. The aim of this study was to identify and categorize GNS research based on health system domains.

METHODS

PubMed, CINAHL, and Embase were searched for GNS literature published from 1999 to 2019. Then, health system domains were defined and itemized based on publicly available documents from the Program in Global Surgery and Social Change. This items chart was subsequently used to categorize the GNS literature into health system domains.

RESULTS

A total 63 articles were determined to focus on a health system domain. Of these articles, 6 focused on multiple domains, yielding an adjusted total of 70 articles. Overall, the most represented health system domain was service delivery (21 articles), followed by workforce (19), infrastructure (15), financing (12) and information management (3). A total of 30 low- and middle-income countries (LMICs) were represented across all articles. In addition, the first author was affiliated with an institution from a high-income country for 71.4% of the articles.

CONCLUSIONS

This review highlighted the pressing need for more research into information management in the context of GNS. In addition, health system-focused GNS literature represented only 20% of all LMICs (30/143). The trends in authorship should be noted, because many ethical (and practical) issues may arise if there is a disconnect in the objectives of the authors and the neurosurgeons in LMICs.

Access to the Intensive Care Unit by Severe Head Injury Patients

Background The management of severe traumatic brain injury is directed at avoidance of secondary brain injuries. The intensive care unit (ICU) provides the ideal environment to achieving improved survival and functional outcome. The study sets out to identify the factors that determine the access of patients with severe head injury presenting at our hospital, to the ICU and their impact on outcome. Materials and Methods his was a longitudinal study at the University College Hospital, Ibadan. Data of all consecutive severe head injury patients over a 9-month period, presenting to the accident and emergency department, was collected and analyzed using descriptive statistics and chi-squared test. The level of significance was p < 0.05. Result There were 36 males (80.0%) in our study, with road crashes (25; 79.5%) as the most common mechanism of injury. Most patients (33; 73.3%) were transferred to our center after initial care in another hospital. Though 31(68.9%) patients had access to the ICU, they were all delayed, with the most common reason for the delay being lack of ICU space. More patients who got admitted into ICU (14; 45.2%) were alive at 28 days into admission ( p = 0.04). The females (6; 13.3%) significantly survived till 28 days on admission compared with males ( p = 0.03), but there was no difference in the survival rates between children and adults. Conclusion Our study underscores the need for ICU admission in these patients to optimize outcome and identify the nonavailability of beds, as the most important cause of delayed access, as well as the need for increased manpower capacity and organized resource utilization.

CERVICAL SPINAL CORD INJURY FROM A VEHICULAR ACCIDENTAL NEAR HANGING INJURY AND NECK MANIPULATIONS

Spinal cord injury is a global problem. It is a devastating life altering condition that is associated with permanent disability and reduced life expectancy. Road traffic accident has been described in global literature as the commonest aetiology and second to it is falls. Identifying these factors have led to development of policies and advocacy to reduce these causes of spinal cord injuries. We present three cases of spinal cord injuries from unusual aetiologies viz-a-viz an accidental hanging which resulted in a C4 traumatic myelopathy Frankel A in a 30-year old artisan, playful neck manipulation in a 23-year old male student, resulting in Brown-Sequard syndrome, which resolved with non-operative spinal cord injury management protocol over six weeks and a C4 traumatic myelopathy Frankel D with a 50% anterior listhesis of C4 on C5 in a 50-year old man who sustained injuries from a choke hold 10 weeks prior to presentation. He recovered fully on non-operative management and discharged home Frankel E.