|Year : 2018 | Volume
| Issue : 4 | Page : 159-165
Neurosurgical operative interventions in a new neurosurgical centre in resource-limited settings: A hospital-based study in Nigeria
David O Udoh1, George A Akpede2, Emmanuel C Obeta1, Uyiosa Osazuwa1, Sampson Tudjegbe3, Dafe Akpodoado3
1 Department of Neurological Surgeon, University of Benin Teaching Hospital, P.M.B.1111, Benin City, Edo State, Nigeria
2 Department of Neurological Surgery, University of Benin Teaching Hospital, P.M.B.1111, Benin City, Edo State, Nigeria
3 Department of Anaesthesiology, University of Benin Teaching Hospital, P.M.B.1111, Benin City, Edo State, Nigeria
|Date of Submission||15-Oct-2019|
|Date of Acceptance||22-Jun-2019|
|Date of Web Publication||10-Feb-2020|
Dr. David O Udoh
Division of Neurological Surgery, Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State 300283
Source of Support: None, Conflict of Interest: None
Background: Neurosurgical operations commenced in this institution (which was established in 1973) in 2006. Serving populations of 10 to 12 million, it was, until 2014, the sole neurosurgical facility in the mid-western regions of the country where the demand for neurosurgical care - especially neurotrauma, congenital anomalies, intracranial tumour and degenerative diseases - is very high. We undertook an audit of neurosurgical operations highlighting limitations to effective care and factors influencing outcome.
Patients and Method: We studied retrospectively the demographic data, the indications for and nature of operations, as well as outcomes, in neurosurgical patients at our teaching hospital between June 2006 and August 2014.
Results: A total of 1,184 patients (51% of all neurosurgical admissions) underwent operative procedures during the eight-year period. Male to female ratio was 2.4 to 1. Most operations were performed in patients aged 0-10 years (25.4%); this was followed by patients aged 21-30 years (17.5%) and >60 years (17.14%). Among patients operated in their first decade of life, those aged 2 years and under accounted for the vast majority (208 i.e. 17.6%). The leading indications were traumatic brain injury (28%), hydrocephalus (16%), chronic subdural haematoma (14%), intracranial tumours (12%) and spinal canal stenoses (10.7%). However, in children 2 years and below, congenital anomalies were the commonest indication for surgery. Operative mortality was 6.25%; this was higher in operations for brain tumours and in the elderly.
Conclusion: The profile of central nervous system surgery in Benin City, Nigeria over eight years underscores the need for improvement in the available neurosurgical services, personnel training and facility to meet the escalating society demands.
Keywords: Hydrocephalus, intracranial tumours, neurosurgical operations
|How to cite this article:|
Udoh DO, Akpede GA, Obeta EC, Osazuwa U, Tudjegbe S, Akpodoado D. Neurosurgical operative interventions in a new neurosurgical centre in resource-limited settings: A hospital-based study in Nigeria. Arch Int Surg 2018;8:159-65
|How to cite this URL:|
Udoh DO, Akpede GA, Obeta EC, Osazuwa U, Tudjegbe S, Akpodoado D. Neurosurgical operative interventions in a new neurosurgical centre in resource-limited settings: A hospital-based study in Nigeria. Arch Int Surg [serial online] 2018 [cited 2020 Apr 1];8:159-65. Available from: http://www.archintsurg.org/text.asp?2018/8/4/159/278021
| Introduction|| |
There are very few neurosurgeons (1: 4,000,000 population) in Africa, located especially in urban facilities and, as a result, most African population have no access to neurosurgical care., Many tertiary hospitals in developing countries grapple with conflicts in achieving a balance between expansion (in terms of increased bed space and admission capacity) and funding the demands imposed by such growth such as staffing, technology and equipment, and training. While more surgical patients are admitted into new bed spaces, the operating room facilities (and other support equipment) and staffing do not increase commensurately.
We present here an audit of neurosurgical operations at our tertiary care facility from inception and some of the factors limiting optimal utilization of limited available resources.
| Patients and Methods|| |
This was a retrospective study of all 1,184 patients who underwent neurosurgical operations between June 2006 and August 2014. Data on demography, indications for operations and outcomes were obtained from case file (and operating room) records as well as the computerized log of all admitted patients. Postoperative outcomes (survival or death) were also documented.
The admission protocol included detailed neurosurgical evaluation as well as radiological and laboratory examinations. They were all classified either as emergency or elective cases depending on the neurological status at presentation and/or findings on neuroimaging. All patients with brain and spinal trauma and intracranial abscesses were operated as emergencies while other patients were taken as emergencies only in the event of neurological deterioration.
Radiological evaluation [plain radiographs, ultrasonography, computerized tomography (CT), and/or magnetic resonance imaging (MRI)] was used to determine which patients required operative interventions. Other preoperative examinations included chest radiographs, electrocardiography, echocardiography and laboratory analyses (e.g. complete blood counts, blood sugar, clotting profile, and cerebrospinal fluid analyses). Only the minimum necessary investigation, especially hematocrit, blood sugar, serum biochemistry, and CT scan were performed in expeditious situations.
Thorough multidisciplinary evaluation which included ophthalmic, otorhinolaryngologic, and cardiorespiratory specialist reviews were carried out before all elective operations and, where especially indicated in some emergency operations.
Postoperatively, patients were either transferred to the neurosurgical ward after a satisfactory postoperative review or to the intensive care unit (ICU). The critically ill patients were admitted into the ICU before and/or after surgery.
Perioperative management protocol for elective surgeries:
All patients scheduled for elective surgery were first examined for underlying medical conditions which required control or precluded surgery. Preoperative anaesthesiologists' review to assess fitness was carried out at least 24 h before surgery. Our protocol for antibiotic prophylaxis is intravenous ceftriaxone given at induction of anesthesia.
Intraoperatively, the wound is irrigated using ceftriaxone and gentamicin constituted in warm saline until wound closure.
Twelve patients were excluded. They included those who had undergone neurosurgical procedures at other facilities admitted for neurosurgical nonoperative care. The others were patients transferred after surgery under other subspecialty services within our hospital that were now inoperable from multiple intracranial metastases and/or poor clinical and neurological status.
| Results|| |
One thousand, one hundred and eighty-four (1,184) patients underwent various neurosurgical operations at our center from June 2006 to August 2014. This represented 52% of all 2,260 neurosurgical admissions into our facility [Figure 1].
|Figure 1: Comparison of Yearly Neurosurgical Admissions to Operations and Operative Mortality|
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The ages ranged from 13 days to 87 years. The overall male to female ratio was 2.4:1 [Table 1].
|Table 1: Age and Sex specific Distribution of Patients who Underwent Neurosurgical Operations over Eight Years According to Diagnoses. (n=1184)|
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Operations by age
Most operations were performed in patients aged 0–10 years, that is, 301 (25.4%), most of whom were aged 0–2 years (i.e. 208, 17.6%), followed by 21–30 years (17.5%), and >60 years (17.14%). The others were 3–10 years (7.85%), 11–20 years (9.5%), 31–40 years (12.41%), 41–50 years (8%), and 51–60 years (10%) [Table 1].
In patients 10 years and below, operations were performed for hydrocephalus (137, i.e. 46%), spina bifida (63, i.e. 21%), cranial trauma (37, i.e. 12.5%), brain tumors (20, i.e. 6.7%), intracranial abscess (16, i.e. 5.4%), encephalocoeles (10, i.e. 3.4%), subgaleal cyst and other cranial dermoids (8, i.e. 2.7%), craniosynostosis (5, i.e. 1.7%), and cranioplasty for skull defects (1, i.e. 0.3%). In children 2 years and below, brain trauma was infrequent and spinal cord injury was not seen; however, 19% of operations for intracranial abscess involved in this group were females, while congenital anomalies were mostly found in males in the same age group [Table 1], [Figure 2].
In patients aged 21–30 years, that is, 207, 113 (55%) patients were operated for brain trauma, spinal cord injury (28, i.e. 13.5%), and tumors (23, i.e. 11%); the others had cranioplasty for skull defect (11, i.e. 5%), hydrocephalus (10, i.e. 4.8%), subdural hematoma (9, i.e. 4.3%), abscess (7, i.e. 3.4%), canal stenoses (4, i.e. 2%), and subgaleal cyst (2, i.e. 1%). There were no cases of spina bifida or encephalocoeles [Table 1].
In the elderly (i.e. 203 surgeries), most were performed for chronic subdural hematoma, CSDH, (88, i.e. 43%), spinal canal stenoses (64, i.e. 31.5%), brain tumors (24, i.e. 11.8%), and brain trauma (21, i.e. 10%); there were 2 (i.e. 1%) each for spinal cord injury, hydrocephalus, and brain abscess. There were no cases of spina bifida, encephalocoeles, craniosynostosis, and other cranioplasties, or dermoids in this group [Table 1].
Operations by diagnoses
Of all 1,184 surgeries, most operations were performed for brain trauma (330, i.e. 28%), followed by hydrocephalus (187, i.e. 16%), chronic subdural hematoma (171, i.e. 14%), intracranial tumors (144, i.e. 12%), spinal stenoses (127, i.e. 10.7%), spina bifida (64, i.e. 5.4%), intracranial abscess (59, i.e. 5%), and spine trauma (55, i.e. 4.8%); the others were cranioplasties (18, i.e. 15.8%), encephalocoeles (12, i.e. 1%), dermoids (11, i.e. 0.9%), and craniosynostosis (6, i.e. 0.5%) [Table 1]; [Figure 2].
Patients aged 21–30 years accounted for most operations for brain trauma (113, i.e. 34%) and spinal trauma (55 of 64, i.e. 86%). Patients aged 0–10 years predominated in operations for congenital anomalies such as hydrocephalus (137, i.e. 73%), spina bifida (63, i.e. 98%), encephalocoeles (all 12 were aged 0–2 years), craniosynostosis (all 6 aged 0–10 years), and dermoids (73%) [Table 1].
Most patients who had surgeries for intracranial abscesses were aged 11–20 years (23 of 59, i.e. 39%) and 0–10 years (16, i.e. 27%) [Table 1].
Operations for CSDH were performed mostly in the elderly (88 of 171, i.e. 51.5%) and spinal canal stenosis in patients in their sixth decade and above (104 of 127, i.e. 82%). Cranioplasties for skull defects were not carried out in the first decade or after the fifth decade. Operations for intracranial (and 2 spinal) tumors included all ages, but were rare before the age of 2 years [Table 1].
Neurosurgical ward to intensive care admissions
The ratio of neurosurgical ward to ICUadmissions was ratio 6: 1 with ICU admission being more common for traumatic brain injury and intracranial tumors [Figure 3].
|Figure 3: Comparison of Ward and ICU Admissions to their respective Total and Postoperative Deaths|
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Declining volume of surgeries
From inception in 2006–2009, total yearly admissions as well as operation volumes increased progressively. A minimal reduction in these figures occurred from 2009 to 2010. A considerable decline occurred over 2 years from 2013 to 2014.
Overall there were 74 (6%) postoperative deaths. Patients with intracranial tumors, brain trauma, patients aged 10 years and below and the elderly accounted for 31%, 24%, 23%, and 20% of the overall mortality, respectively [Figure 1] and [Figure 3].
Operative mortality per diagnosis
The postoperative mortality was 16% among patients who had operations for tumors, spinal injury 9%, intracranial abscess 8.5%, encephalocoele 8.3%, traumatic brain injury 5.5%, CSDH 5.3%, hydrocephalus 3.7%, and canal stenoses and spina bifida had 3% each. The mean was 5.7% [Table 2] and [Figure 4].
|Figure 4: Operative Mortality by Diagnoses. TBI: Traumatic Brain Injury; CSDH: Chronic Subdural Hematoma; SCI: Spinal Cord Injury|
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Operative mortality per age group
Comparing number of deaths with operations in each age group postoperative death in the age group 0–10 years was 5.6%, 11–20 years 8.8%, 21–30 years 5.3%, 31–40 years 5.4%, 41–50 years 6.3%, 51–60 years 6%, and above 60 years 7.4%. The mean was 6% [Table 2].
Neurosurgical postoperative mortality represented 32% of total neurosurgical mortality. Between 2006 and 2014, the number of operations increased four- to six-fold while perioperative mortality increased less than threefold [Figures 3].
| Discussion|| |
While attracting a large inflow of surgical patients into various surgical specialties, the operating room, seen ostensibly as the functional epicentre of a hospital, requires considerable resource.
The volume and outcome relationship of neurosurgical operations are affected by three major factors in resource-limited settings. Patient factors such as socioeconomic status, age, size, type and location of the lesion, pre-morbid status, and the mode of presentation. Secondly, the experience and skill of the attendant team, quality of the operating and monitoring equipment, duration of the surgery and volume of blood loss, and operating room conditions. Thirdly, affecting the foregoing directly or indirectly, are hospital and government policies which influence the initial Workforce, type and size of facility and equipment, and staffing including a neurocritical care personnel. The latter ultimately determine admission volumes and, indirectly, outcomes.
Large volume of blood is lost in major neurosurgical operations compared with the moderate amounts lost during other operations. Certain aspects of blood loss and water balance in the brain must be understood and judiciously managed in order to avoid serious disturbances during prolonged operations.,,,,,,, The anesthesiologist and neurosurgeon need to make a reasonably accurate estimate of blood loss, so ostensibly, by the suction apparatus, and that which is absorbed by drapes, multiple small pledgets and the contents of the suction bottle.,,
Where no resection of brain tissue is carried out, hemorrhage occurs during incision or closure of the scalp, or from the skull.
The choice of anesthetic and method of anesthesia also influence blood loss and outcome during neurosurgical operations. Ether and nitrous oxide cause excessive bleeding secondary to cerebral vasodilatation and rise in intracranial pressure, cerebral perfusion pressure, and blood pressure, respectively.,
In spite of excessive bleeding, neurosurgical patients rarely go into shock if less than 1,200 cc of blood is lost unless hemorrhage is rapid or there is damage to centers which control respiration and circulation.
Thus, the neurosurgeon should ensure meticulous hemostasis which, though time consuming, is worthwhile.
Recognizing 1,500 cc as the maximum tolerable blood loss in the average patient, it is advisable to transfuse or postpone surgery to a second stage (when possible) when this limit is approached.
Globally, there is a diminished involvement and availability of emergency care by various surgical specialists, including neurologic surgeons, as physicians and shortage, disparate with population growth, per decade, becomes apparent. The persistently low neurosurgeon to population ratio, reflective of progressively lower physician to population ratio, may be due to a numerus clausus.,,,,
The supply and demand for health professionals are affected by a number of factors that may or may not be under the control of policymakers or health professionals themselves due to constraints such as resistance to change and lack of relevant information. Unlike in our, and most other African, setting, developed nations are involved extensively in the planning of the health workforce. The authorities can shape the medical workforce either in the short term (by importing foreign medical graduates into vacant posts) or in the long term (by increasing or decreasing the numerus clausus to cope with shortage or oversupply., Policymakers need to be impressed upon to know that efforts to improve quality of care and reduce costs will not be effective unless qualified physicians are available to provide that care.,
The evolution of image-guided biopsies and craniotomy has lent excellent safety profile to neurosurgery as well as made outpatient (awake) craniotomy possible.,
In our facility, the ratio of neurosurgical ward to ICU admissions was 6: 1. Since postoperative mechanical ventilation was required mostly by patients with intracranial tumors, its availability frequently determined whether surgery was carried out or rescheduled [Figure 4].
Countries with fewer neurosurgeons per population, an index of development, tend to have less neurosurgical operations per population and vice versa.,,,,
Neurosurgical operations at our institution went through a period of steady rise from inception in 2006–2008. A modest increase between 2008 and 2009 was followed by a shallow dip in operations—despite constantly escalating admissions—from the beginning of 2009 to the end of 2010 which resulted from closure of the main theatre and ICU complex for government-assisted upgrading. The emergency theatre which erstwhile was used for minor procedures did not have enough spaces for all the hospital's operating units; neither could it meet the demands of several neurosurgical procedures because of lack of an attached ICU. A deeper decline over two years from 2013 to 2014 was accounted for by several industrial actions which frequently stalls hospital activities, especially surgical operations for long periods. Between 2006 and 2014, neurosurgical ICU admission have increased six times, but total admissions have only quadrupled.
Our operative options did not include endoscopic, vascular, or stereotactic neurosurgery due to lack of equipment; a ready solution would be to put back resources from high yield units to improve efficacy rather than have their contributions to hospital growth used for hospital maintenance unrelated to neurosurgery.
The technology used in neurosurgery s rapidly evolving. Stereotactic surgery is minimally invasive surgery with extreme accuracy; it is the computerized link between a CT scan (or MRI) and the operating room equipment. This technique enables the neurosurgeon to precisely place a needle on a very small lesion or tumor with an accuracy of 1 mm. Neuronavigation is the application of 3D views of the patient's brain or spinal cord that are linked by computer to the instruments used during surgery. It includes stereotactic surgery. An example is the brain lab neuronavigational system. Newer techniques incorporate neuronavigation to maximize accuracy and minimize risk.,,
Thus, worldwide disparities in surgical disease distribution and access to optimal surgical care are increasingly obvious resulting in collaborations between academic medical centers (and non-profit organizations) in North America and Europe, such as Vanderbilt, Harvard Medical Centre, University of Southern California, and a host of others with hospitals in developing countries such as in Uganda, Nigeria, Kenya, Botswana, Haiti and Rwanda in the last three decades.,
In Benin City, Nigeria, our fledging neurosurgical facility has partnered with the Korle Bu Neuroscience Foundation (KBNF), and as a result with leading neurosurgeons, neuroscience nurses, anesthesiologists, intensivists, and biomedical engineers from Johns Hopkins, Vancouver General Hospital, Atlanta and Accra since 2009. It is, however, important that these partnerships be aimed at developing future leaders in global surgery placing local capacity building as ultimate goal.,
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]