Surgical management of spinal tuberculosis in Papua New Guinea

Two cases of spinal tuberculosis (TB) presented with deteriorating myelopathy despite chemotherapy. Surgery of anterior decompression and fusion was successfully carried out resulting in both the patients ambulating and being continent on discharge. This highlights the importance of early surgery and a multidisciplinary approach to the management of this condition.

Space-occupying lesions in Papua New Guinea--the CT era

BACKGROUND: The use of computed tomography (CT) scanning to diagnose and treat space-occupying lesions (SOL) has been a great advance. AIM: To analyze the causes, treatment and outcome of SOL. METHOD/PATIENTS: An audit of all cases of SOL treated over a period of 2 years (2003-2004) after the establishment of a neurosurgical unit. RESULTS: There were 42 SOL cases affecting the intracranial space and the spine. 39 cases originated in the brain and its coverings and 3 in the spinal cord. Out of the 39 brain SOL, 26 (67%) were due to tumours and 13 (33%) were due to infection, of which tuberculosis was responsible for 6 (46%). There were 6 astrocytomas and 3 meningiomas followed by secondaries, pilocytic astrocytoma and medulloblastoma with 2 cases each. There was also one case each of pineal tumour, craniopharyngioma, pituitary adenoma, vestibular schwannoma and oligodendroglioma and 6 indeterminate cases. The 3 spinal cord SOL were due to arachnoiditis, subdural abscess and tuberculoma. CONCLUSION: Tumours were more common than tuberculosis as a cause of SOL. However, tuberculoma represented a curable condition whereas for tumours the potential for cure depended on the site, pathology and stage. CT scan was of great help in the diagnosis and localization of SOL but, unfortunately,is still not available for the majority of the Papua New Guinea population.

Big heads in Port Moresby General Hospital: an audit of hydrocephalus cases seen from 2003 to 2004

BACKGROUND: Hydrocephalus is a common neurosurgical problem in Port Moresby General Hospital (PMGH) contributing to 27 (24%) of the 114 neurosurgical operations done in 2003 and 2004. During the same period it was responsible for 25% of the cases seen in the neurosurgery clinic. AIM: To prospectively audit and follow up hydrocephalus cases in PMGH over 2 years from January 2003 to December 2004 and ascertain the causes and the outcome of treatment. METHOD: All cases of hydrocephalus seen in 2003 and 2004 were categorized according to cause. The associated findings on ultrasound scan or CT (computed tomography) scan when available were noted. The subsequent progress was documented with and without treatment for at least 6 months. RESULTS: 61 cases of hydrocephalus were seen for surgical opinion. The age ranged from 4 weeks to 56 years. The commonest age group affected was in the first year of life (61% of cases). There were 34 cases (56%) of congenital hydrocephalus followed by 19 (31%) post meningitis and 8 (13%) due to tumour. There was only one case of myelomeningocele with concomitant hydrocephalus. Ventriculoperitoneal (VP) shunts were inserted in 24 cases. 3 shunts were bypasses from the posterior horn to the cisterna magna, making a total of 27 shunt operations. 9 shunts were performed for post-meningitic hydrocephalus, 15 for congenital stenosis and 3 for a posterior fossa tumour. 24 out of the 27 shunt operations were in children aged <9 months. Post-VP-shunt infection of 2 cases reported within 6 weeks of operation gave an infection rate of 7%. There was cerebrospinal fluid (CSF) leak in 2 cases with Pundez-type shunts. There were 2 shunt blocks needing revision. CONCLUSION: Shunt operations can be done in PMGH with good outcomes. The decision-making about surgery can be made on the basis of the enlarging head and the ultrasound findings.

Trends in traumatic brain injury outcomes in Port Moresby General Hospital from January 2003 to December 2004

BACKGROUND: Traumatic brain injury (TBI) has been responsible for 25-30% of surgical deaths in Port Moresby General Hospital (PMGH) over the last 30 years despite being responsible for only 5% of the admissions. AIM: To document the epidemiology of TBI over a period of two years from 2003 to 2004 and compare this to the previous two decades in PMGH and elsewhere. The treatment and outcome of TBI cases are analyzed. METHODS: All TBI cases were included from January 2003 to December 2004. The Glasgow Coma Score (GCS) and Glasgow Outcome Scale (GOS) were documented at admission and discharge. These cases were followed up in the outpatient department for at least 6 months. RESULTS: There were 262 cases of TBI admitted between January 2003 and December 2004. There were 31 deaths during this period. 28 deaths were in the severe TBI category (GCS 3-8) and 3 in the moderate category (GCS 9-12). CONCLUSION: The case fatality rate of severe TBI has been reduced from 60% to just below 30% over the period of 2 years. The formation of a single unit managing TBI over two years may be one factor contributing to this improvement. Interpersonal violence has replaced motor vehicle accidents as the leading cause of death from TBI.

Open depressed and penetrating skull fractures in Port Moresby General Hospital from 2003 to 2005

BACKGROUND: Open wounds to the head with skull bone depression pose the potential for serious injuries to the brain parenchyma and an increased risk of infection. The treatment of these injuries aims to repair the breached dura as well as remove any nidus for infection. Open wounds to the head due to bullets pose special problems and have a high fatality rate. AIM: To review the presentation, management and outcome of depressed and penetrating open fractures of the skull in Port Moresby. METHOD: All cases seen from 2003 to 2005 were included. All were managed without a CT (computed tomography) scan. Their Glasgow Outcome Scale (GOS) was documented on discharge. RESULTS: There were 340 traumatic brain injury (TBI) cases over a period of 3 years between 2003 and 2005 managed by the Neurosurgery Unit of Port Moresby General Hospital. The open depressed and penetrating skull fractures seen in these cases numbered 46 (14%), of which 42 were males and 4 females. The weapons most commonly used were blunt objects (16), knives (11), guns (6) and axes (4). Gunshots contributed to 4 of the 7 deaths. 4 out of the 7 deaths were due to primary brain injury and 3 were due to infection. CONCLUSION: Open depressed fractures and penetrating injuries form a small but significant group in the management of head injuries. The use of blunt objects, firearms and arrows coupled with increasing urban violence is responsible for most of these injuries. The outcome of patients admitted who are fully conscious is expected to be good. They can be managed by prompt debridement of the wound, elevation of the fracture and removal of fragments as appropriate. However, the mortality rate is high in those with a Glasgow Coma Score of 8 or less on admission, a finding indicative of the severity of brain injury beneath the wound.

Monitoring traumatic brain injury in Papua New Guinea

Continuous appraisal of clinical indices with appropriate tests and their recording as evidence of treatment are conducive for evidence-based management of traumatic brain injury (TBI). Monitoring of various neurological indices and relating them to set parameters of TBI is imperative for gauging ongoing treatment. These parameters include cerebral oxygenation, cerebral perfusion pressure (CPP) and intracranial pressure (ICP). These are measured directly or by use of transcranial Doppler complemented with microdialysis, which is in the frontiers of research. The use of an ICP monitor and computed tomography (CT) scan is part of the standard repertoire of intensive care for the management of TBI. In Papua New Guinea where there are no ICP monitors or CT scan, the detection of increased ICP or intracranial mass lesions is done by thorough neurological examination complemented by monitoring of oxygen saturation, blood pressure and the Glasgow Coma Score.

Neuroprotection in traumatic brain injury: practical implications for Papua New Guinea and some research developments

Given the lack of infrastructure in Papua New Guinea (PNG) traumatic brain injury (TBI) cases are usually not retrieved quickly to medical centres. Cases that eventually reach the hospital do so after the golden hour has passed. This means that the brain is already at risk of or is already subject to secondary brain injury. In TBI, the parenchymal integrity of the normal, the penumbrous and the lacerated tissue needs to be kept in a state of balance, such that the normal tissue is not compromised. The whole aim of neuroprotection is to protect the normal brain parenchyma from further injury. Secondary brain injury is minimized by reducing cerebral oedema and intracranial pressure, in order to improve cerebral blood flow and perfusion. This guideline describes the options for neuroprotection in PNG.

A practical approach to the management of head injuries in Papua New Guinea

Traumatic brain injury (TBI) is one of 3 leading causes of deaths in the Surgery Department of Port Moresby General Hospital in the last 30 years despite being responsible for only 5% of admissions. It maims and kills the young. Most of these injuries and deaths can be prevented by addressing public health issues such as modifying people's lifestyles to avoid drink driving, wearing seat belts in vehicles and peaceful conflict resolution. Severe disabilities can be minimized by prompt and adequate management that prevents secondary brain injury. This is achieved by aggressive maintenance of normal cerebral oxygenation and blood pressure (BP) and optimization of intracranial pressure (ICP). These outcomes are achieved by ensuring that the airways are patent, with respiration assisted where necessary, and by the use of fluids or inotropes to maintain a normal BP. Prompt appreciation of mass lesions and their removal will optimize ICP, improve cerebral perfusion pressure (CPP) and oxygenation. Management of severe TBI involves appropriate use of ventilation and pharmacological agents to ensure ICP and CPP are optimized either in situations where surgery is not indicated or after decompressive surgery. The high morbidity and mortality posed by TBI can be reduced by addressing these issues in Papua New Guinea.

The management of spine pathology in Papua New Guinea

This paper outlines the principles of the management of different spinal diseases. In Port Moresby General Hospital between 2004 and 2006 there were 41 spinal injuries, 36 cases of spinal tuberculosis (8 of whom were operated on), 3 non-tuberculous infections and 11 degenerative conditions. The incidence of spinal dysraphism is low in Papua New Guinea with only 5 cases recorded in Port Moresby over the 3-year period. Identification and assessment of spinal pathology were sometimes limited by a lack of radiological investigation and often the resources were not available for optimal treatment. 8 cases with myelopathy had no definitive diagnosis made.