An Ethiopian Training Program in Neurosurgery with Norwegian Support.

After a 4-year planning period, a joint Ethiopian/Norwegian training program in neurosurgery was started in June 2006. The collaborating partners were Addis Ababa University; Department of Surgery, Tikur Anbessa Specialized Hospital; University of Bergen; Haukeland University Hospital; and Myungsung Christian Medical Center, a Korean missionary hospital in Addis Ababa, Ethiopia. A memorandum of understanding was signed at dean/chief executive officer levels. Although other initiatives have been involved in supporting neurosurgery in Addis Ababa during the same period, this institutionally founded program has been the main external contributor to neurosurgical capacity building through the education of 21 Ethiopian neurosurgeons, and in supporting a sustainable environment for neurosurgical training within a network of 5 centers in Addis Ababa. This article gives an account of the strategies underlying the program planning, the history of the program, and on the experience gained by it. Finally, ethical problems and challenges encountered in the program are discussed.

Review of lumbar disc diseases at Tikur Anbessa Hospital.

BACKGROUND: Disc degeneration is common, the pattern and prevalence of various signs of disc degeneration is unclear. Neither hospital nor population-based data or study is available on lumbar disc diseases in Ethiopia. The sequelae of disk degeneration are among the leading causes of functional incapacity in both sexes and are a common source of chronic disability in the working years. Lumbar disc disease refers to a collection of degenerative disorders that can lead to low back pain as people age. OBJECTIVE: Review the pattern, clinical manifestation, diagnostic method and management decision of patients with degenerative lumbar disc disease at the neurosurgical referral clinic of Tikur Anbessa Hospital during the fiscal year 2009. PATIENTS AND METHODS: This is a hospital based cross sectional study of patterns of patients with lumbar disc diseases seen at the neurosurgical referral clinic, Tikur Anbessa Specialized Teaching Hospital (TASTH), Department of Surgery, Addis Ababa, Ethiopia in the period between January and December 2009 (12 months). Data taken while clerking patients and patents' medical record at referral clinic were main source of information. Standardized and structured questionnaire prepared for this purpose were used to analyze the sociodemographic, clinical manifestation, diagnostic modalities such as lumbar myelography, CT and MRI, patterns of disc disease in lumbar spine at NSRC with reference to age, severity and level distribution were reviewed. Difference in proportions were examined using Chi-square test. RESULTS: The study reviews 364 patients with lumbar disc diseases at the neurosurgical referral clinic, TASH over the one-year period (2009), their age ranged from 20 to 82 years (median, 44.0). Pain, numbness and neurologic claudication were the three most common presenting symptoms, occurring in 337(92.5%), 232 (63.7.6%) and 111 (30.5%) respectively. Lumbar MRI was the statistically significant investigation modality of choice (p < 0.0001). Two hundred thirty-five (70.1%) patients had disc prolaps (P < 0.0001), 18.5% had disc bulge. Lumbar degenerative disc disease was most frequently seen at L4-L5 level in 309 (54.5%) patients (P < 0.0001). both L4-L5 and L5-S1 accounted for 79.1% of the disc displacements. On MRI, disc displacements, were central in 61.2%, lateral in 9.3% and posterolateral in 15.8%.

The consequence of delayed neurosurgical care at Tikur Anbessa Hospital, Addis Ababa, Ethiopia.

Tikur Anbessa Hospital (TAH) is the major teaching hospital for Addis Ababa University and the only tertiary referral hospital for neurosurgery in Ethiopia. We explore the consequence of delayed treatment by examining the current system in place for treating patients and the wait times experienced by patients. A retrospective chart review was carried out on patients who received a neurosurgical operation at TAH between January 1 and June 30, 2007. We divided patients into those requiring an elective procedure and those requiring emergency surgical care. Based on data entered in the chart, we determined the length of time from symptom onset to neurosurgical consultation and the time from consultation to receiving an operation. Selective cases were chosen to illustrate the effects of delayed care. A total of 172 neurosurgical operations were performed between January 1 and June 30, 2007, at TAH. Of these, 107 (62.2%) charts were available for retrospective review. Fifty-six elective cases were reviewed. The median time from symptom onset to neurosurgical consultation was 185 days. The median time from neurosurgical consultation to operation was 44 days. Fifty-one trauma/emergency surgical cases were reviewed. The median time from symptom onset or traumatic event to neurosurgical consultation was 3 days. The median time from neurosurgical consultation to operation was 1 day. Delayed neurosurgical care comes with a high personal and social cost. By measuring the time from diagnosis to treatment and taking note of institutional practices, changes can be initiated to improve patient waiting times.

In-patient surgical mortality in Tikur Anbessa Hospital: a five-year review.

BACKGROUND: To our knowledge neither hospital nor population-based data is available about mortality patterns in Ethiopia. OBJECTIVE: This review summarizes the patterns of deaths that occurred in hospital under the care of surgical team, during the 5-year period. PATIENTS AND METHODS: This is a hospital based retrospective cross sectional analysis of mortality among surgical patients admitted to Tikur Anbessa Specialized Teaching Hospital (TASTH), Department of Surgery, Addis Ababa, Ethiopia in the period between January 2002 and December 2006. The monthly activity reports, death registry sheets and death certificate of deceased patients from all surgical wards were analyzed using computer based statistical software SPSS version 11.0. Difference in proportions were examined using Chi-square test with its conventional criterion for statistical significance (p < 0.05). RESULTS: The study reviews 694 deaths from 9991 surgical admissions, and 9860 procedures at TASTH over the 5-year period. There were 6.9% overall deaths among the admissions and 7.0% per procedure. The postoperative mortality rate was 4.5% (443/9860). The male-to-female ratio was 2.9:1. The mean age was 41 [Standard Deviation, 17.38] years. Four hundred fifty-two (15.7%) patients admitted on emergency basis and 242 (3.4%) of elective admissions died while in hospital surgical care (p < 0.0001). About 56% of deaths resulted from non-traumatic causes whilst 44% from traumatic causes. Similarly operative deaths were observed in 443 (63.8%) while nonoperative mortality in 252 (32.2%). Among patients with trauma, isolated head injury (59.2%) was major cause of death (p < 0.0001), while, of the non-traumatic admissions, malignancy accounted for 164 (42.1%) of the deaths, When specialties are compared, significant number, 234 (34.4%) of the deaths belong to neurosurgery unit (p < 0.0001) followed by general surgery. CONCLUSION: In conclusion, more men died than women did, more patients admitted on emergency basis died than patients admitted on elective basis (p < 0.0001). Although, the overall mortality rate of 7% and postoperative death rate of 4.5% is acceptable, it could have been reduced significantly had there been appropriate setting to manage trauma cases. Trauma and Neurosurgical cares are yet to develop and need special attention.

Injury surveillance in six hospitals of Addis Ababa, Ethiopia.

OBJECTIVE: This surveillance was initiated to see the hospital burden of injuries and as a pilot to test the injury surveillance integration in Ethiopia. BACKGROUND: Injury is becoming the major health problems in low income countries. Though it is important cause of mortality and morbidity, due attention is not given by the low-income countries. METHODS: This surveillance was conducted in six major hospitals of Addis Ababa, Ethiopia from February 1, 2003 to August 31, 2003. RESULTS: In total, 9000 patients related to injury visited the hospitals in this period. Majority of the injury patients visited the hospitals were males (73.2%) and the majority of the injury patients (72.5%) were in the age groups 15-44 years old. Struck/hit (45.7%) and road traffic injury (24.2%) were the leading causes of injury and falls with 11.5% follows the two. In terms of intent, 65.3% were unintentional and 31.8% were related to assaults. CONCLUSION: Injuries are important problems for Addis Ababa, Ethiopia and needs further community based study to determine the burden in the society. The surveillance system should be also integrated with the national health surveillance system.

Meningiomas: clinical correlates, skull x-ray, CT and pathological evaluations.

OBJECTIVE: To assess the frequency and the diagnostic performance of plain skull x-ray and and CT of meningiomas. METHODS: All pathologically diagnosed intracranial meningiomas in patients seen at Tikur Anbessa Hospitals were reviewed. RESULTS: Between December 1999 and July 2004 there were 25 histologically diagnosed cases of meningioma at the Tikur Anbessa Hospital (TAH). The duration of symptoms was ranging from 0.5-10 yrs. (mean 2.4 +/- 2.1 yrs) and age ranging from 21-57 yrs (mean age of 49.3 +/- 10 yrs.) with M:F ratio of 1.2:1. Blurring of vision was the commonest clinical presentation. Clinical correlates, skull x-rays, computerized tomographic results and pathology are evaluated. Plain skull x-ray findings were normal in 12/23 (52%); 10/23(43%) of the cases had non-specific sellar changes of raised intra-cranial pressure. Twenty-three of the 25 meningiomas had CT scanning done, and CT diagnosed 17/23 (74%) meningiomas correctly. Two meningiomas were unusual in location: one was intranasal and the other was intra-ventricular. Parasellar tumors were frequent sites of misdiagnosis. The commonest locations were parasellar and cerebral convexity, each accounting for 6/25 (24%) of the cases. The commonest CT observation was intense and homogeneous enhancement 15/23 (65%). Meningothelial meningioma was the commonest cellular type accounting for 11/25 (46%) of the pathologies followed by the transitional 4/25 (16%) and the atypical and psammomatous types, each with equalfrequency, 3/25 (12%). CONCLUSION: CT scan had a diagnostic accuracy of 83%, sensitivity of 74%, specificity of 95%, positive predictive value (PPV) of 95%, and negative predictive value (NPV) of 75%. Statistical analysis verifies the pre-operative reliability for diagnosing meningiomas by CT scanning.

Intramedullary cavernous haemangioma of spinal cord: a case report and literature review.

A 27-year-old female patient with progressive paraparesis and incontinence of urine of 9 months duration was managed at Tikur Anbessa Hospital, Neurosurgery unit, Department Of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa. Thoracic myelography showed an intramedullary mass at T3-T5 levels of the spinal cord. Histopathology revealed cavernous haemangioma. Near total surgical removal of the haemangioma was done. and the patient put on intensive physiotherap. Cavernous haemangioma should be suspected in the differential diagnosis of patients with progressive deterioration of spinal cord function. Total surgical excision of the lesion is the current treatment modality.

Surgical management of carpal tunnel syndrome in neurosurgery practice in Ethiopia and review of literature.

Carpal tunnel compression of the median nerve is a common condition with an estimated incidence of 0.1% to 10% and a direct medical cost of above dollars 1 billion per year in the USA. Between the years 1995 to 2002, 28 cases, 6 (21.4%) males and 22 (87.6%) females of mild to severe forms of carpal tunnel syndrome (CTS) were seen and treated by the author in Tikur Anbessa Hospital (TAH) Neurosurgery Unit and a private hospital in Addis Ababa. Of the 28 cases, 22 (87.6%) patients, 7/22 (31.8%) mild and 15/22 (68.2%) severe forms, were surgically treated with the open surgery method. The male to female ratio was 1:3.7 and the age range 28-52 years, with a mean of 40.6 +/- 7.2 and the Confidence Interval of the mean 37.7-43.0; a median of 40 yrs and a mode of 40. Fifty percent of the cases were below 35 years and 75% below 46.75 years. The duration of illness was from 6 months to 8 years. There were 8/28 (28.6%) females with bilateral conditions. All the males had right sided carpal tunnel syndrome; the right hands were more involved in 23 (63.9%) cases while left hands only in 13 (36.1%) patients. All 22 patients were much relieved of the aching pains in the respective hands 3-5 days postoperatively and by 3 months 5 patients, the only ones who reported for follow-up, showed much reduced numbness and paraesthesiae with fairly good gripping capacity of the operated hands, though wasting and atrophy of the thenar eminences persisted requiring adequate exercise and early physiotherapy. There is no recurrence or worsening of the illness reported. Carpal tunnel syndrome is a treatable condition. It is stressed that an open surgery, required division of the flexor retinaculium and palmar aponeurosis extending to distal base attachment of the thenar eminence in the hand, is essential for the definitive treatment and to avoid any recurrence. Open surgery is easy and cheap and can be done by the general surgeon with a good anatomical knowledge of the hand.

Trauma registry in Tikur Anbessa Hospital, Addis Ababa, Ethiopia.

A simplified trauma registry was tested in Tikur anbessa hospital, with the aim of obtaining preliminary data on the patterns and magnitude of injuries and establishing the basis towards surveillance system. All injured patients presented to the surgical and pediatric emergency department between January 1, 1999 and June 31, 1999 were included. Interns completed the registry forms, which include demographic, injury event specific, severity and outcome data. The severity was assessed by new scoring system, Kampla Trauma Score (KTS). Among the 3822 injured patients 2869(75%) were males and 953(25%) were females and 80% were below the age of 40 years. 77% of the injuries were unintentional and motor vehicle injuries accounted for 41% of all causes among which 93% of them were pedestrians. Accidental fall and interpersonal assault accounted for 21% and 20% respectively. Admitted cases were 11.6%, while 20 (.5%) died at the outpatient department with the overall mortality of 1.47%. Though burn and gunshot accounted only for 6%, the case fatality rate was highest (4%) accounting for 20% of all deaths. The magnitude of fatal injuries is underestimated and the pattern of injuries may only reflect the situation in the big cities. Motor vehicle injuries, especially pedestrian injuries are serious problem in Addis as seen in patients in Tikur Anbessa hospital and require further situational studies and urgent intervention. Establishing hospital based simplified injury surveillance system is possible in Ethiopia and it is essential to asses the magnitude of the problem and identify priority area for injury prevention and control.

Management of cervical ribs causing neurogenic thoracic outlet syndrome: a ten year experience in the neurosurgery unit, Tikur Anbessa Hospital.

Eighteen cases of cervical Ribs causing numbness, paraesthesia and wasting of hand muscles were seen during the years 1990 to 1999 in neurosurgery unit of Tikur Anbessa, a central, referral teaching hospital. There were thirteen cases of unilateral, and 5 bilateral brachialgic pains M:F = 1:2 with ages range from 15-50 yrs (mean age 32 +/- 4.8 yrs); though it is 3 times common in women specially those with neurologic symptoms. 5 cases didn't have any cervical ribs. All had respective cervical rib resections and scalenotomy done. Paraesthesia and pain were relieved in about 90% of the cases. Cervical rib causing Thoracic Outlet Syndrome (TOS) is a rare condition commonly seen in less than 1% of the population as seen here in 18 cases in 10 years period. The absence of cervical rib doesn't rule out thoracic outlet syndrome as it can be from anomalous first ribs, scalenus anticus syndrome or congenital fibromuscular bands. Surgical excision has a good neurological outcome. No subclavian vessel especially arterial compression cases were seen in this study as cervical ribs can cause neurovascular compression. The diagnostic and therapeutic measures are clearly stated as this syndrome is a diagnostic and treatment challenge to the practicing general surgeons. Accurate diagnosis and proper surgical intervention are very crucial for the good outcome.