The surgical treatment of traumatic leptomeningeal cyst (LMC) is repair of the dural defect with or without cranioplasty. The dural substitutes used are either autografts (which may not be enough) or ...artificial grafts (which are foreign-body implantations and which also may be too expensive in a
low
-resource practice). In this report from a developing country, we present the surgical description of the use of the cyst capsule as a cost-free autologous graft in the surgical repair of the dural defects of two cases of traumatic leptomeningeal cyst.
Introduction: Although neurosurgical surgical site infections (SSI) exert a devastating price on the postoperative course of patients in the developing countries, literature is sparse on the subject ...from these regions.
Methods: This study is an audit of post-craniotomy SSI in a sub-Sahara African academic neurosurgical practice. It is a retrospective descriptive analysis of neurosurgical SSI in a 7-year consecutive cohort of patients who survived more than 5 days following major cranial surgery. Our general neurosurgical operative goal is to keep the incidence of SSI as close to the global range as possible by, amongst other measures, enforcing strict compliance with appropriate operative room practice.
Results: There were 211 craniotomies/craniectomies; 194 primary and 17 redo procedures. Male patients constituted 65%. The mean age was 32.2 (Standard Deviation +/− 17.2) years. The procedures were emergencies in 42.7% and urgent or elective in the rest. They were surgery for trauma in 46.9% and for tumour resections in 44.1%. The median duration of surgery was 3 hours (range 1-8.5 hours). Mortality was 4.3%. Functional outcome was assessed using a dichotomized Glasgow Outcome Scale and was good in 90.5%. Surgical site infections, mainly by Gram negative coliforms, occurred in 9 cases, 4.3%, leading to worse in-hospital outcome of 56% (p < .001) in those affected. Patients with a poorer pre-operative Karnofsky performance status had a higher infection rate (7.5%), than those with better clinical performance index, (2.3%). This difference was not significant (p = .09, unadjusted OR 3.46, 95% Confidence Interval 0.84-14.24).
Conclusion: Post-craniotomy SSI rates comparable to those in more advanced practice areas is achievable in developing countries
Africa and other Asian low middle-income countries account for the greatest burden of the global road-traffic injury (RTI)-related head injury (HI). This study set out to describe the incidence, ...causation, and severity of RTI-related HI and associated injuries in a Nigerian academic neurosurgical practice.
This is a retrospective cross-sectional analysis of RTI-related HI from a prospective HI registry in an academic neurosurgery practice in Nigeria.
All-terrain RTI accounted for 80.6% (833/1,034) of HI over a 7-year study period. All age groups were involved, mean 33.06 years (SD 18.30), mode 21-30, 231/833 (27.7%). The male:female ratio was 631:202, ≈3:1. The road trauma occurred exclusively from motorcycle-and motor-vehicle crash (MCC/MVC), MCC caused 56.8% (473/833) of these; the victims were vulnerable road users (VRU) in 74%, and >90% belong in the low socioeconomic class. Using the Glasgow Coma Scale grading, the HI was moderate/severe in 52%; loss of consciousness occurred in 93%, the Abbreviated Injury Severity-head > 3 in 74%, and computed tomography (CT) Rotterdam score > 3 in 52%. Significant extracranial injuries occurred in many organ systems, 421/833 (50.5%) having Injury Severity Score (ISS) > 25. Surgical lesions included extensive brain contusions in 157 (18.8%); acute extradural hematoma in 34 (4.1%); acute subdural hematoma in 32 (3.8%); and traumatic intracerebral hemorrhage in 27 (3.2%), but only 97 (11.6%) received operative care for various logistic reasons. The in-hospital outcome was good in 71.3% and poor in 28.7%; the statistically significant (
< 0.001) determinants of this outcome profile were the severity of the HI, the CT Rotterdam score, and the ISS.
In this study from Nigeria, RTI-related HI emanates from significant trauma to vulnerable road users and are caused exclusively by motorcycles and motor vehicles.
Major craniotomy is currently the de facto operative treatment for traumatic acute extradural hematoma (AEDH). This craniotomy, involving extensive scalp dissection (the trauma flap) and major ...cranial bone opening, can be impracticable in the remote regions of some Western countries, and even more so in the low-resource health systems of most developing countries.
We describe the surgical technique of minicraniotomy under local anesthesia plus monitored sedation as a much less invasive operative treatment for AEDH. The results of its use in a preliminary patient group are also presented.
The procedure has been carried out in 10 consecutive patients (7 men), including an infant 4 months of age. The age range was 4 months to 56 years. The patients suffered varying severity of head injury, with a median Glasgow Coma Scale (GCS) score of 11 out of 15 (range, 4–15). The median trauma to surgery time was 25 hours (range, 13–192 hours). The surgery was successfully completed, with hematoma evacuated and hemostasis achieved. The median duration of surgery was 90 minutes. The in-hospital outcome was Glasgow Outcome Scale score of normal status in 6 patients, moderate deficit in 2 patients, and vegetative state in the patient whose preoperative GCS score was 4. One other patient, admitted with a GCS score of 11, died 5 days postoperatively from extracranial causes. The surviving patients have been followed-up for a median time of 15 months with no new deficits.
Compared with full craniotomy under general anesthesia, minicraniotomy under local anesthesia plus sedation may be a more pragmatic, less invasive, and low-cost surgical treatment option for uncomplicated traumatic acute extradural hematoma.
Hinge craniotomy (HC) is a technique that allows for a degree of decompression whilst retaining the bone flap in situ, in a ‘floating’ or ‘hinged’ fashion. This provides expansion potential for ...ensuing cerebral oedema whilst obviating the need for cranioplasty in the future. The exact indications, technique and outcomes of this procedure have yet to be determined, but it is likely that HC provides an alternative technique to decompressive craniectomy (DC) in certain contexts. The primary objective was to collate and describe the current evidence base for HC, including perioperative parameters, functional outcomes and complications. The secondary objective was to identify current nomenclature, operative technique and operative decision-making. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Fifteen studies totalling 283 patients (mean age 45.1 and M:F 199:46) were included. There were 12 different terms for HC. The survival rate of the cohort was 74.6% (
n
= 211). Nine patients (3.2%) required subsequent formal DC. Six studies compared HC to DC following traumatic brain injury (TBI) and stroke, finding at least equivalent control of intracranial pressure (ICP). These studies also reported reduced rates of complications, including infection, in HC compared to DC. We have described the current evidence base of HC. There is no evidence of substantially worse outcomes compared to DC, although no randomised trials were identified. Eventually, a randomised trial will be useful to determine if HC should be offered as first-line treatment when indicated.
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).
The authors conducted a prospective observational study of all neurotrauma patients managed at their center over a 36-month period beginning in August 2018.
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.
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.
Decompressive craniectomy (DC) has many technical details with significant constraining logistic/economic considerations in low-resource practice areas. We present a less invasive, cost-saving, and ...evidence-based technique of DC evolving in our practice.
Earlier, we reported a technique of hinge decompressive craniectomy (hDC), in which the frontotemporoparietal skull flap is hinged on the temporal muscle. In this article we describe further refinements of this temporal muscle hDC : The scalp flap is raised in a galeal-skeletonizing plane preserving the subgaleal fascia on the pericranium, ready for use for duraplasty after durotomy. We performed a descriptive analysis of the clinical outcome of this surgical technique in a prospective consecutive cohort of patients with traumatic brain injury (TBI). The primary and secondary clinical outcome measures were in-hospital mortality and survival, respectively, and the immediate as well as long-term surgical wound issues.
There were 40 cases, 38 men (95%) and 2 women over a 40-month period with a mild (n = 8), moderate (n = 17), or severe TBI (n = 15). As assessed by the computed tomography Rotterdam score, life-threatening significant brain injury was present in 90%. Poor clinical outcome occurred in about a third of cases (32.5%) mainly in the severe TBI group (77% of poor outcome) and not in the mild TBI group. Surgical site complications occurred in four patients (10%)
The presented modified temporal muscle hDC technique offers significant economic advantages over the traditional surgical method of DC without added complications. Analysis of the clinical data in a consecutive prospective cohort of patients with potentially fatal TBI who underwent this surgical procedure showed a good outcome in at least two thirds.
Nonshaved neurosurgery, cranial or spinal, is well reported among Caucasians but hardly among native Africans. The ungroomed scalp hairs of black Africans have unique anthropological characteristics ...needing special attention for shaveless cranial surgery. A technical report of the execution of this surgical procedure among an indigenous patient population in a sub-Sahara African country is presented, as well as an outcome analysis in a prospective cohort over a 7-year period. A total of 303 patients (211 males, 70 %) fulfilled the criteria for this study. The surgical procedure was primary in 278 (92 %) and redo in 8 %. It was emergency surgery in 153 (51 %). They were trauma craniotomies or decompressive craniectomies in 95 cases (31 %), craniotomies for tumour resections in 86 (28 %), and the surgical dissections for other conditions in 122 (41 %). The duration of surgery ranged from 30 min to 8.5 h, mean 2.5 (SD, 1.6), median 2. In-hospital clinical outcome was good (normal status or moderate deficit on dichotomized Glasgow outcome scale (GOS)) in 273 (90.1 %) cases while surgical site infections occurred in only 10 cases (3.3 %). The type of surgery, redo or primary, did not have any significant association with the in-hospital outcome (
p
= 0.5), nor with the presence of surgical site infection (SSI) (
p
= 0.7). The length of follow-up ranged from 2 to 63 months (mean, 7) with no untoward complications reported so far. Medium-term outcome of nonshaved neurosurgery in this indigenous black Africans remains favourable with no attendant significant adverse after-effects.
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