A Geospatial Analysis of the Availability, Distribution, and Accessibility of Neurosurgical Facilities, Workforce, and Infrastructure in Nigeria; and Projection Towards 2050.

OBJECTIVE: There has been a modest but progressive increase in the neurosurgical workforce, training, and service delivery in Nigeria in the last 2 decades. However, these resources are unevenly distributed. This study aimed to quantitatively assess the availability and distribution of neurosurgical resources in Nigeria while projecting the needed workforce capacity up to 2050. METHODS: An online survey of Nigerian neurosurgeons and residents assessed the country's neurosurgical infrastructure, workforce, and resources. The results were analyzed descriptively, and geospatial analysis was used to map their distribution. A projection model was fitted to predict workforce targets for 2022-2050. RESULTS: Out of 86 neurosurgery-capable health facilities, 65.1% were public hospitals, with only 17.4% accredited for residency training. Dedicated hospital beds and operating rooms for neurosurgery make up only 4.0% and 15.4% of the total, respectively. The population disease burden is estimated at 50.2 per 100,000, while the operative coverage was 153.2 cases per neurosurgeon. There are currently 132 neurosurgeons and 114 neurosurgery residents for a population of 218 million (ratio 1:1.65 million). There is an annual growth rate of 8.3%, resulting in a projected deficit of 1113 neurosurgeons by 2030 and 1104 by 2050. Timely access to neurosurgical care ranges from 21.6% to 86.7% of the population within different timeframes. CONCLUSIONS: Collaborative interventions are needed to address gaps in Nigeria's neurosurgical capacity. Investments in training, infrastructure, and funding are necessary for sustainable development and optimized outcomes.

Management and outcomes of pediatric traumatic brain injury in Africa: a systematic review.

OBJECTIVE: Traumatic brain injury (TBI) carries a major global burden of disease; however, it is well established that patients in low- and middle-income countries, such as those in Africa, have higher mortality rates. Pediatric TBI, specifically, is a documented cause for concern as injuries to the developing brain have been shown to lead to cognitive, psychosocial, and motor problems in adulthood. The purpose of this study was to investigate the reported demographics, causes, management, and outcomes of pediatric TBI in Africa. METHODS: A literature search was conducted using PubMed, Global Index Medicus, Embase, Scopus, Google Scholar, African Journals Online, and Web of Science. Various combinations of "traumatic brain injury," "head injury," "p(a)ediatric," "Africa," and country names were used. Relevant primary data published in the English language were included and subjected to a risk of bias analysis. Variables included age, sex, TBI severity, TBI cause, imaging findings, treatment, complications, and outcome. RESULTS: After screening, 45 articles comprising 11,635 patients were included. The mean patient age was 6.48 ± 2.13 years, and 66.3% of patients were male. Of patients with reported data, mild, moderate, and severe TBIs were reported in 57.6%, 14.5%, and 27.9% of patients, respectively. Road traffic accidents were the most reported cause of pediatric TBI (50.53%) followed by falls (25.18%). Skull fractures and intracerebral contusions were the most reported imaging findings (28.32% and 16.77%, respectively). The most reported symptoms included loss of consciousness (24.4%) and motor deficits (17.1%). Surgical management was reported in 28.66% of patients, with craniotomy being the most commonly reported procedure (15.04%). Good recovery (Glasgow Outcome Scale score 5, Glasgow Outcome Scale-Extended score 7-8) was reported in 47.17% of patients. Examination of the period post-2015 demonstrated increased spread in the literature regarding pediatric TBI in Africa. CONCLUSIONS: This study provides a comprehensive overview of the literature regarding pediatric TBI in Africa and how it has evolved alongside global neurosurgical efforts. Although there has been increased involvement from various African countries in the neurosurgical literature, there remains a relative paucity of data on this subject. Standardized reporting protocols for patient care may aid in future studies seeking to synthesize data. Finally, further studies should seek to correlate the trends seen in this study, with primary epidemiological data to gain deeper insight into the disease burden of pediatric TBI in Africa.

The status of specialist neurosurgical training in Nigeria: A survey of practitioners, trainers, and trainees.

OBJECTIVE: Despite the well-known neurosurgical workforce deficit in Sub-Saharan Africa, there remains a low number of neurosurgical training programs in Nigeria. This study sought to re-assess the current status of specialist neurosurgical training in the country. METHODS: An electronic survey was distributed to all consultant neurosurgeons and neurosurgery residents in Nigeria. Demographic information and questions relating to the content, process, strengths, and challenges of neurosurgical training were explored as part of a broader survey assessing neurosurgical capacity. Descriptive statistics were used for analysis. RESULTS: Respondents identified 15 neurosurgical training centers in Nigeria. All 15 are accredited by the West African College of Surgeons (WACS), and 6 by the National Postgraduate Medical College of Nigeria (NPMCN). The average duration of core neurosurgical training was 5 years. Some identified strengths of Nigerian neurosurgical training included learning opportunities provided to residents, recent growth in the neurosurgical training capacity, and satisfaction with training. Challenges included a continued low number of training programs compared to the population density, lack of subspecialty training programs, and inadequate training infrastructure. CONCLUSION: Despite the high number of neurosurgery training centers in Nigeria, compared to other West African countries, the programs are still limited in number and capacity. Although this study shows apparent trainee satisfaction with the training process and contents, multiple challenges exist. Efforts at improving training capacity should focus on continuing the development and expansion of current programs, commencing subspecialty training, driving health insurance to improve funding, and increasing available infrastructure for training.

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.

Fulfilling the specialist neurosurgical workforce needs in Africa: a systematic review and projection toward 2030.

OBJECTIVE: Africa contributes significantly to the global neurosurgical disease burden but has only 1% of the neurosurgery workforce. This study appraises the neurosurgical workforce and training capacity in Africa and projects the workforce capacity by 2030. METHODS: The authors conducted a systematic review of the online literature on neurosurgical workforce and training in Africa obtained from three journal databases (PubMed, Embase, and African Index Medicus), as well as from a gray literature search, between September and December 2020. Included literature passed a two-level screening conducted using a systematic review software by a team of two independent reviewers. Data were extracted from selected articles and documented and analyzed on spreadsheets. RESULTS: One hundred and fifty-nine eligible articles were analyzed: 1974 neurosurgeons serve 1.3 billion people in Africa (density 0.15 per 100,000 persons, ratio 1:678,740), with uneven distribution between the regions. North Africa has 64.39% of the neurosurgical workforce (n = 1271), followed by Southern Africa (12.66%, n = 250), West Africa (11.60%, n = 229), East Africa (8.26%, n = 163), and Central Africa (3.09%, n = 61). At an exponential growth rate of 7.03% (95% CI 5.83%-8.23%) per annum, Africa will have 3418 (95% CI 1811-6080) neurosurgeons by 2030, with a deficit of 5191 neurosurgeons, based on population workforce targets. In terms of training, there are 106 neurosurgery training institutions in 26 African countries. North Africa has 52 training centers (49.05%), West Africa 23 (21.70%), East Africa 15 (14.15%), Southern Africa 14 (13.21%), and Central Africa 2 (1.89%). The major regional training programs are those of the West African College of Surgeons (24 sites in 7 countries) and the College of Surgeons of East, Central, and Southern Africa (17 sites in 8 countries). CONCLUSIONS: The study is limited as it is based on the online literature, some of which includes modeled estimates with questionable reliability. However, the results indicate that while countries in North Africa are expected to surpass their population workforce requirements, sub-Saharan African countries are likely to have significant workforce deficits accentuated by the paucity of neurosurgery training programs. To meet the 2030 population workforce requirements, the continent's exponential growth rate should be scaled up to 15.87% per annum. Scaling up neurosurgical training would help to meet this target and requires collaborative efforts from continental, regional, and national agencies and international organizations.

Intra-operative wound irrigation with ceftriaxone does not reduce surgical site infection in clean neurosurgical procedures.

BACKGROUND: The spectrum of post-operative infections in neurosurgical practice includes scalp infection, bone flap osteomyelitis, meningitis and intracranial abscesses and is associated with significant morbidity and mortality. There is a wide variation across neurosurgical centres in the use of perioperative antibiotic prophylaxis. The aim of this study was to determine whether intraoperative wound irrigation with ceftriaxone provides additional prevention of surgical site infection (SSI) in patients already receiving the drug parenterally. METHODS: This was a prospective randomized clinical study of patients 18 years and above scheduled for clean neurosurgical procedures and assigned to either study or control group using table of random numbers. Both groups had parenteral ceftriaxone at the induction of anaesthesia and for 24-h post-operation. In the study group, there was intra-operative wound irrigation with a ceftriaxone-in-normal saline solution while the wound in the control group was irrigated with only normal saline. Clinical and or laboratory evidence of SSI was used as the outcome measure. RESULTS: One hundred and thirty-two patients aged 18 years and above were recruited for this study. There were 66 patients in each group. The overall frequency of SSI was 2.27% (3 out of 132). The frequency in the ceftriaxone group was 3% (2 out of 66) while that in the control group was 1.5% (1 out of 66). These values were not significantly different (p = 1.00). There were four cases of wound edge necrosis, three of which developed SSIs. CONCLUSION: In this study, intraoperative antibiotic irrigation did not confer additional benefit in the prevention of SSI in clean neurosurgical procedures in which prophylactic intravenous antibiotics were administered to the patient. Wound edge necrosis was the most significant but preventable risk factor for the development of SSI in the setting of this work.

Dendritic and Synaptic Degeneration in Pyramidal Neurons of the Sensorimotor Cortex in Neonatal Mice With Kaolin-Induced Hydrocephalus.

Obstructive hydrocephalus is a brain disorder in which the circulation of cerebrospinal fluid (CSF) is altered in a manner that causes expansion of fluid-filled intracranial compartments particularly the ventricles. The pyramidal neurons of the sensorimotor cortex are excitatory in nature and their dendritic spines are targets of excitatory synapses. This study evaluated the effect of hydrocephalus on dendritic arborization and synaptic structure of the pyramidal neurons of the sensorimotor cortex of neonatal hydrocephalic mice. Sterile kaolin suspension (0.01 ml of 250 mg/mL) was injected intracisternally into day old mice. Control animals mice received sham injections. Pups were weighed and sacrificed on postnatal days (PND) 7, 14 and 21. Fixed brain tissue blocks were silver impregnated using a modified Golgi staining technique and immunolabeled with synaptophysin to determine dendritic morphology and synaptic integrity respectively. Data were analyzed using ANOVA at α 0.05. Golgi staining revealed diminished arborization of the basal dendrites and loss of dendritic spines in the pyramidal neurons of hydrocephalic mice. Compared to age-matched controls, there was a significant reduction in the percentage immunoreactivity of anti-synaptophysin in hydrocephalic mice on PND 7 (14.26 ± 1.91% vs. 62.57 ± 9.40%), PND 14 (4.19 ± 1.57% vs. 93.01 ± 1.66%) and PND 21 (17.55 ± 2.76% vs. 99.11 ± 0.63%) respectively. These alterations suggest impaired neuronal connections that are essential for the development of cortical circuits and may be the structural basis of the neurobehavioral deficits observed in neonatal hydrocephalus.

Outcome of cranial surgery in Nigerian patients with hemoglobinopathies: A retrospective study.

BACKGROUND: Surgical intervention in patients with hemoglobinopathies has been extensively reviewed in the literature, but information on the outcome of cranial surgery in this patient population in sub-Saharan Africa is limited. METHODS: This is a retrospective study of patients with hemoglobinopathies, who underwent brain surgery in our facility. The review covered a 5-year period. We examined patient- and surgery-related variables and described the surgical complications as well as the 60-day mortality. RESULTS: A total of nine procedures (eight under general anesthesia and one under local anesthesia) were performed on seven patients with hemoglobinopathy during the study period. Eight (88.9%) of these were done in female patients and one (11.1%) in a male patient. Six (66.7%) were performed in patients with no previous history of blood transfusion. Hb SC accounted for five (55.6%), Hb SS for three (33.3%), and Hb CC for one (11.1%) procedure, respectively. Three (33.3%) of these procedures were brain tumor-related, three (33.3%) trauma-related, one (11.1%) cosmetic, one (11.1%) vascular, and one for a postoperative complication. Only one (11.1%) procedure was associated with preoperative blood transfusion, whereas there was a need for blood transfusion following five (55.6%) of the procedures. There was a mortality rate of 11.1% (1 case). Other complications were recorded after three (33.3%) of the procedures and none with five (55.6%) of the procedures. CONCLUSION: Neurosurgery is possible and safe in patients with hemoglobin disorders. Adequate preoperative preparation, proper anesthetic techniques, meticulous surgery, and excellent postoperative care can help optimize outcome of surgical intervention in this patient population.

Delleman-Oorthuys syndrome (oculocerebrocutaneous syndrome) in a Nigerian child: a case report.

BACKGROUND: Delleman-Oorthuys syndrome, also known as oculocerebrocutaneous syndrome, is a rare congenital anomaly with ocular, cerebral and cutaneous manifestations. So far, only 40 cases have been described. CLINICAL CASE: A 3-year-old female Nigerian child with no identifiable left eyeball, multiple left-sided facial skin defects and delayed developmental milestones but otherwise uneventful medical and family history was evaluated at the Ophthalmology and Paediatric Neurosurgery in Ibadan, Nigeria. Besides the mentioned defects that were present since birth, brain imaging revealed several brain abnormalities including intracranial cysts. Global hyperreflexia and bilateral flexor plantar response were observed upon clinical examination. Left micro-ophthalmia and orbital mass were detected. A histological assessment of the orbital mass revealed it to be rudimentary ocular tissue. The diagnosis of Delleman-Oorthuys syndrome was made based on the clinico-radiological features. The patient underwent a left-sided posterior fossa cystoperitoneal shunt. The left orbital mass was enuclated and the patient is currently awaiting left eyelid reconstruction and an orbital implant and repair of the left alar nasi cleft. CONCLUSION: To our knowledge, this is the first published report of Delleman-Oorthuys syndrome in a female child of West African descent. Given the variable manifestations of Delleman-Oorthuys syndrome, and overlap with other syndromes, the Delleman-Oorthuys syndrome may be underreported. Neuroimaging of patients with cutaneous tags, orbital cysts and micro-ophthalmia could reveal more cases.

Effect of preconception gamma irradiation on morphometric assessment of adult female mice and embryo / Efecto de la irradiación gamma preconcepción sobre la evaluación morfométrica de ratones hembras adultas y embriones

The aim was to study the effect of preconception gamma irradiation on the gross morphometry of the adult female mice and its embryo. Twenty-seven mice; 18 females and 9 males: subdivided into 3 groups namely (Control, Non-Irradiation and Radiation) containing 6 females and 3 male mice each in 2:1 ratio. A gamma irradiation dose of 1Gy/min was delivered to each batch of mice exposed by a Cobalt 60, Theratron 780c model, by Atomic Energy of Canada Limited (AECL) at the Radiotherapy department of the University College Hospital, Ibadan. All the animals were mated 1 week post irradiation. Vaginal plugs were confirmed, and the pregnant females were sacrificed on day 14 of gestation by chloroform inhalation. The gross morphology of the female mice and their harvested litters were assessed and statistically analysed. A total of 113 embryos were harvested in all groups; 54 for Control, 50 for Non-Irradiated and 9 for the irradiation group. The gross morphologic assessments of the fetuses were statistically significant at P value < 0.05 for all the 3 groups compared. These findings suggest that a preconception irradiation affects the morphology of the female mice and its progeny.

El objetivo fue estudiar el efecto de la irradiación gamma antes de la concepción sobre la morfometría macroscópica de ratones hembra adultos y los embriones de sus crías. Veinte y siete ratones, 18 hembras y 9 machos, divididos en 3 grupos (control, sin irradiación e irradiado) con 6 hembras y 3 machos cada uno en proporción 2:1. Una dosis de radiación gamma de 1 Gy/min fue aplicada a uno de los ratones expuestos por un equipo Cobalt 60, Theratron modelo 780c, Atomic Energy of Canada Limited (AECL) en el departamento de radioterapia del Hospital University College de Ibadan. Todos los animales se aparearon 1 semana después de la irradiación. Se confirmaron los tapones vaginales, y las hembras preñadas fueron sacrificadas en el día 14 de la gestación por inhalación de cloroformo. La morfología general de los ratones hembras y sus camadas fueron evaluadas y analizadas estadísticamente. Un total de 113 embriones se recolectaron en todos los grupos, 54 del grupo control, 50 del grupo no irradiados y 9 del grupo irradiado. Las evaluaciones morfológicas macroscópicas de los fetos fueron estadísticamente significativas (p<0,05) para los 3 grupos de comparación. Estos hallazgos sugieren que una irradiación previa a la concepción afecta a la morfología de los ratones hembra y su progenie.

Pattern of presentation of pressure ulcers in traumatic spinal cord injured patients in University College Hospital, Ibadan.

The neurosurgery division in University College Hospital (U.C.H.) admits approximately one traumatic spinal cord injured (SCI) patient per week, most of whom stay a minimum of 42 days on admission. A common complication in these patients is the development of pressure ulcers, which contributes to a longer hospital stay and increased hospital expenses. The purpose of this study was to investigate the pattern of presentation of pressure ulcers in patients on admission and to propose policies or protocols to reduce the incidence. It is a prospective study of traumatic SCI patients managed on the neurosurgery ward from January 2003 to June 2004. The data was analysed using descriptive statistics. Sixty-seven patients were studied. The average hospital stay was 73 days. Thirteen (20%) of the patients were admitted with pressure ulcers, 32 (47·7%) developed it after admission. As much as 87·5% of pressure ulcers seen in the course of this study which occurred on admission in U.C.H. was in the first week of admission, 6·25% in the second week and the remaining 6·25% in the third week. Pressure ulcers were distributed as follows; 69% (42) in the sacral region, 18% (11) trochanteric, 5% (3) scalp, 1·5% (1) ankle, 1·5% (1) ischial tuberosity, the remaining 5% in other sites. Preventive measures for pressure ulcers consisted of basic skin care, pressure dispersion using fenestrated foams and alternating weight-bearing sites by regular turning. Pressure ulcers are commonest in the sacral and gluteal regions and tend to occur within the first week of admission in the neurosurgical wards.