ABSTRACT

Objective

To determine the pattern of neurosurgical diseases presenting to a tertiary health institution in Nigeria, 30 months after the commencement of services, in order to establish the local demographic data base and subsequently, structure service delivery on the evidence-based disease profile.

Methodology

A retrospective study using the admission registers and folders of patients under the Neurosurgery Unit from July 2006 to December 2008. Data tabulation was done with Window’s Excel broadsheet software and the results were collated and analyzed using Epi Info 3.5.1.

Results

A total of 1255 patients were treated in the Unit within the study period, with 206 (16.4%) congenital and 1049 (83.6%) acquired cases. The acquired cases include trauma 860(82%), neoplasms 81 (7.7%), degenerative diseases 76 (7.2%) and infections 32 (3.1%). The majority were males 892 (71.1%), and mostly in the 21-30 year age group 254 (20.2%), and trauma was mostly from road traffic accidents 679 of 860 (78.9%) involving motorcycles, motor vehicles and bicycles. Of the specific indications, head injury was the most common 747 (59.5%), followed by congenital hydrocephalus 148 (11.9%) and spinal injury 94 (7.5%). The cases admitted as in-patient were 567 (45.2%), and 295 [23.5%] spent 1-7 days before discharge. Mortality was 111, representing 13.9% of admissions (or 8.8% of all presenting cases) viz. head injury 86 of 111 (77.5%), spinal injury 10 (9%), neoplasm 9 (8.1%), infections 5 (4.5%) and congenital diseases 1 (0.9%). Most of the deaths, 72 (64.9%) occurred within 72 hours.

Conclusion

The most common indication for neurosurgical consultation in most centres in Nigeria is trauma, and since resources for neurosurgical care are scarce in our country, the focus of care should first be to reduce this major identifiable disease burden by prevention. Provision of facilities, staff and training preferentially for trauma care should therefore be the main priority when setting up new neurosurgical centres to ensure that the greater level of care gets to the greater number of patients.

Key Words: Audit, Demographic Patterns, Epidemiology, hydrocephalus, Manpower, Nigeria, road traffic, trauma

RESUME

Objectif

Déterminer la configuration des maladies neurochirurgicales dans une institution de santé tertiaire au Nigéria 30 mois après l’ouverture des services, afin d’établir une base de données des maladies prises en charge.

Methodes

Une étude rétrospective utilisant les registres d’admission et les dossiers des patients admis dans l’unité de neurochirurgie du juillet 2006 au décembre 2008. L’étude des données a été faite avec les logiciels Window Excel et Epi Info 3.5.1.

Resultats

1255 patients ont été soignés dans l’unité au cours de la période d’étude, avec 206 (16,4%) affections congénitales et 1049 (83,6%) cas acquises. Les cas saisis incluent les traumatismes 860 (82%), les néoplasmes 81 (7,7%), les affections dégeneratives diseases 76 (7.2%) et les infections 32 (3.1%).
La majorité des malades étaient de sexe masculin 892 (71,1%), et principalement dans la tranche d’âge 21-30 ans, 254 (20,2%). Les traumatismes étaient la plupart du temps des accidents de la circulation routière 679 de 860 (78,9%) impliquant des motos, des bicyclettes. Plus spécifiquement, il s’agissait des traumatismes crâniens 747 (59,5%), suivi de l’hydrocéphalie congénitale 148 (11,9%) et des traumatismes du 94 (7.5%). 567 (45,2%) des patients ont été hospitalisés, et 295 [23,5%) ont effectué un séjour de 1-7 jours.
La mortalité était de 111 cas, représentant 13,9% des traumatisés crâniens, 86 d’admissions (ou 8,8% de tous les cas de présentation) à savoir de 86 des 111 patients (77,5%), lésions de la moelle épinière 10 cas (9%), néoplasme 9 cas (8,1%), infections 5 cas (4,5%) et maladies congénitales. La plupart des décès, 72 (64,9%) se sont produits dans un délai de 72 heures.

Conclusion

L’installation de nouveaux centres neurochirurgicaux, la fourniture d’équipements, de personnel et de formation axés préférentiellement pour la prise en charge de la traumatologie devraient être une priorité au Nigéria afin d’assurer une grande qualité des soins plus grand nombre des patients.

Mots clés : Epidémiologie, Hydrocéphalie, Nigéria, Traumatologie.

INTRODUCTION

Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Nigeria was formerly a State General Hospital but in December 1988 when it was acquired for medical training by the State University, it became the Anambra State University Teaching Hospital (ASUTECH) under the Anambra State Government. In 1991 however, it was re-named after the 1st President of the Federal Republic of Nigeria, the Rt. Hon. Dr. Nnamdi Azikiwe, and by September 1992, it was upgraded to a facility of the Federal Government and subsequently, joined the ranks of Federal Teaching Hospitals in Nigeria [16].

It is a tertiary health facility that receives referrals from private, primary, secondary and tertiary centres in and around the South East Zone of Nigeria. Nnewi, is located in Nnewi North Local Government Area of Anambra State, one of the five States that make up the South East zone. It is located on the map between latitude 60 11 0” North and longitude 60 551 0”East, and is a sub-urban town with dilapidated internal road networks that necessitate the predominant use of motorcycles as an easier, faster and cheaper mode of intra-city commuting than motor vehicles [5]. It is a sub-urban town populated mainly by civil/public servants, students from the few schools around, road transport operators, and traders of machine parts and house wares, and the town has minimally available recreational facilities.

Nigeria, with a population, according to the 2006 national census, of more than 140 million, is composed of 36 States grouped unevenly into six geopolitical zones – South East, South West, South South, North Central, North East and North West. Anambra State has a total population of 4,182,032 (males 2,174,641; females 2,007,391) going by the 2006 National Census. The other four States in the same South East zone are Abia State 2,833,999; Ebonyi State 2,173,501; Enugu State 3,257,298 and Imo State 3,934,899. Our new centre has a potential catchment area spread over some parts of three of the six zones viz. South East (11.7% of Nigeria’s population), South South (15% of the population) and North Central (13.5%) – more than a third of the country’s population. It is a 350-bed tertiary facility that provides services in the various specialties of Medicine, with accreditation for undergraduate training as well as postgraduate medical training in different specialties. Neurosurgical services were commenced for the first time in the institution on 20th April, 2006 and before then, there had not been any formal neurosurgical service in the hospital, neither was neurosurgery taught in its medical school. We do not have facilities for Computerized Tomography (CT) presently, but we use the services of two private centres with the facilities. There is a 7-bed Intensive Care Unit (ICU) in our hospital for the care of critically ill patients.
The aim of this study is to review the cases attended to in the Neurosurgical Unit in the 30-month period from July 2006 – December 2008, after the establishment of the Unit as a template for structuring our service delivery to become more relevant to our disease profile in the face of manpower shortage and dwindling material resources. We also hope that this study would be very helpful to other new centres in the sub-region.

MATERIALS AND METHODS

Data collection was done using the Neurosurgery Unit’s admission records and patients’ folders in the hospital over a 30-month period (1st July, 2006 – 31st December, 2008). The data were retrieved using Microsoft Excel broadsheet, and variables collated were age, sex and diagnosis of the patient, date of presentation, source of referral/presentation, date of admission, date of discharge/referral and clinical condition at discharge. Data analysis was done using Epi Info 3.5.1 to determine the distribution of these variables and pattern of neurosurgical patient presentations and admissions, and the findings were then compared with those of other published reports, and some recommendations were made.
Complete spinal cord injuries are those with no residual neurological functions two vertebral levels beyond the site of injury, whereas incomplete cord injuries are those with some residual neurological functions beyond that level resulting in anterior, posterior, lateral and central cord syndromes depemding on the neurological deficits sustained. In other words, patients with complete cervical cord injury are referred to as tetraplegic (incomplete injuries are tetraparetic), whereas those with complete thoracic and lumbosacral injuries are paraplegic (incomplete injuries are paraparetic).

RESULTS

From July 2006 to December 2008, a total of 1255 patients were treated by the Neurosurgery Unit, and 892(71.1%) were males, see figure 1. The age distribution was <1year 162(12.9%), 1-10years 189(15.1%), 11-20years 155(12.4%), 21-30years 254(19.9%), 31-40years 172(13.7%), 41-50years 125(10.0%), 51-60years 88(7.0%] and >60years 110(8.8%), see table 1.

The cases that presented through the Accident and Emergency Unit were 799(63.7%), while those that came through the Out-Patient Clinic and other NAUTH units were 456(36.3%). Congenital factors accounted for 206(16.4%), whereas acquired factors were 1049(83.3%), and a breakdown of the latter showed that trauma accounted for 860(82%), neoplasms 81(6.45%), degenerative lesions 76(6.05%) and infections 32(2.55%), see figure 2.
In individual diagnoses, head injury was the most common 747(59.5%), followed by congenital hydrocephalus 148(11.8%), spinal injuries 128(10.2%), spina bifida 71(5.7%), intracranial neoplasms 52(4.1%), seizures 40(3.2%) and infections 32[2.55%]. Out of the 747 cases of head injury 329 (44%) had basal skull fractures, 282 (37.8%) multifocal cerebral contusions with cerebral oedema, scalp lesions 248 (33.3%), cerebral concussions 194 (26%), compound depressed skull fractures 40 (5.4%), acute subdural haematomata 33 (4.4%), linear skull fractures 28 (3.8%), subarachnoid haemorrhages 13 (1.8%), simple depressed skull fractures 12 (1.6%), intracerebral haematomata 10 (1.3%), acute subdural haematomata 8 (1.07%) and subdural hygromata 9 (1.2%), table 2. Some patients had more than a single pathology, each. Spinal injuries were 105 (8.4%), distributed as cervical 66 (62.9%), thoracic 24(22.8%) and lumbosacral 15 (14.3%). Out of these, 78 (74.3%) had neurological deficits, and 27(25.7%) had no deficits. Complete cord injuries were 37 (35.2%), incomplete 35 (33.3%) and radiculopathies were 6 (5.7%).

Neoplasms were both primary and metastatic; unfortunately, we could not get the histological diagnoses on most of them as they signed for discharge against medical advice, were referred on request to other facilities or absconded from our service after radiologic diagnoses and were not therefore, operated on. Other indications for presentation included acquired hydrocephalus (post-traumatic/ex vacuo) 27(2.2%), microcephaly 11(0.88%), spondylosis 8(0.64%), headache 7(0.56%), craniofacial dysmorphism [Crouzon’s syndrome] 5(0.4%), dementia 2(0.16%), and others, including infections/spinal neoplasms, peripheral neuropathy/neuralgias, etc; accounted for 69[5.5%]. Some patients had more than one disease condition, each.
Most of the 860 cases of trauma-related conditions were due to road traffic accidents 679 (54.1% of 1255) and falls 111(8.84% of 1255) – either from a height or on a level ground. The other forms of trauma included assaults 36(4.2%), missiles 28(3.3%), domestic accidents 5(0.4%) and industrial accident 1(0.08%), see figure 3. The 679 road accident cases, were mostly from motorcycles 501(73.8% of 679), while 176 (25.9%) were from motor vehicles, and 2(0.3%) from bicycles.

The cases admitted for in-patient treatment were 567(45.2%), out of which 55(4.4%) stayed <1 day on observation, 295(23.5%) stayed 1-7 days, 125(9.96%) 2-4 weeks, 11(0.88%) 1-2 months and 4(0.32%) >3months on admission, whereas 77(13.5%) had unspecified duration/incomplete discharge records, see table 3. The cases treated and discharged to the outpatient clinic without admission in the hospital were 596(47.5%), those referred to other facilities were 43(3.42%) and those that signed to be discharged against medical advice were 41(3.27%); while 8(0.64%) absconded from the hospital. Mortality was 111, representing 13.9% of case admissions or 8.8% of all case presentations viz. deaths from head injury 86(6.85%), spinal injury 10(0.8%), neoplasm 9(0.72%), infections 5(0.40%) and congenital diseases 1(0.12%). Most of them, 72 of 111(64.9%), occurred within 72 hours.

DISCUSSION

Our new Unit treated all types of neurosurgical diseases both congenital and acquired, though the acquired cases, especially from trauma, were in the majority. It is, therefore, explicable that the young age preponderance in our cases is reflective of the historical pattern of trauma, since most of them are in the 20-40year age group [2,3,5,7,9,13]. This, most likely, explains the male gender preponderance as well, since it is known that trauma is the leading cause of neurosurgical diseases in this gender-age group. Expectedly, more infants presented with congenital diseases than any other age group, whereas neoplasms were most common beyond 60years of age (figure 4). Also, noteworthy is the female preponderance at the extremes of age in all disease conditions including trauma, and in all other disease presentations at all ages, except for trauma (figures 5 and 6). This implies that if trauma is excluded from the disease profile, more females than males would be expected to present with neurosurgical diseases, in our service.
With the head injury incidence rate at 59.5%, our study compares proportionately with a 3-year study in Ethiopia, in which most (35.3%) of the neurosurgical cases was head injury [2]. In Qatar, Mezue reported that 43.1% of head injuries resulted from road traffic accidents while 33.6% were from falls. Adeolu reported passenger motor vehicular accident as the leading cause (65.3%) of head injury, followed by fall (16.4%), in 1130 patients from South West Nigeria [3]. Both reports, also correlated with the distribution of the aetiologic factors in our service, even though the RTA:fall of 43.1%:33.6% ratio of the former is much less than the 72%:12.2%, in our study [9].
However, the Qatar male:female ratio of 3.3:1 compares closely with ours, 2.5:1, just like published reports by Adeolu, Kemp, Kolenda, Muhammad, Muyembe, Adeloye, Ohaegbulam, Shokunbi, and others correlated with the preponderance of the male gender and head injury in the distribution of neurosurgical diseases [1,2,3, 7, 8, 9, 10, 11, 12, 13,15,17,19]. Unlike the age distribution in our study, with the majority [19.9%] aged 21-30 years and mostly resulting from RTA, the modal age incidence in Qatar is ≤10 years and in this age group, falls were predominant in that report [9]. The observation that nearly 75% of the admitted cases were discharged home in stable neurological condition from our Unit within one week is a possible reflection of the extent of head injuries sustained by these patients, the majority of which was mild.

Of particular note is the pre-eminence of hydrocephalus over the other diseases including spinal injuries and infections, as the second most common indication for seeking neurosurgical consultation in our centre. In a situation such as ours, in a developing country with trauma as the main indication for presentations, the expectation would be that infections rather than hydrocephalus would closely come after trauma; but this was not the case. A low incidence of infective diseases could be understood as a healthy development if the real reason for this is that the incidence of infective neurosurgical cases is low in our practice, possibly reflecting improving standards of living in our country. However, on the other hand, the question may be asked, whether this curious finding was a result of the indiscriminate use of antibiotics in our environment, non-recognition of such cases by other clinicians as requiring neurosurgical attention, or death of such patients before orthodox medical attention could be sought.
In designing the protocols for establishing neurosurgical units in developing countries, it becomes pertinent to realize that an evidence-based profile of the patterns of disease distribution would be paramount in the training of personnel or procurement and acquisition of equipment and materials for the care of the population. Evidently, this pattern of disease distribution varies from region to region, whereas the available resources, including manpower and equipment, are grossly inadequate in every part of Nigeria.

In this study, despite the fact that all disease patterns were reflected in the presentations, the 3:1 ratio of trauma against all other disease conditions put together, calls for a more pragmatic and pro-active approach towards the reduction of the burden of trauma in our environment by the relevant organs of government concerned with appropriate and effective policy formulation and implementation. In a 2006 study of the status of Neurosurgery in Nigeria, we reported that there was an appalling ratio of 1 neurosurgeon to 10mllion Nigerians (10,000,000) [6]. Even though this situation has improved marginally in the past 3years, it is still a far cry from the ideal ratio of 1:81,000 reported for North America.
A Culturelink report had warned in 1996 that with Nigeria’s Gross Domestic Product (GDP) per capita declining from 1,000 US dollars in 1980 to 250 dollars in 1990, population growth estimated at 3.2 per cent, life expectancy at 51 years, and male/female adult literacy limited to 54/31 per cent, the over-all situation of the majority of people appeared unsatisfactory [4]. By 2006, according to United Nations’ Development Programme (UNDP) Human Development Report, these stated ratings by Culturelink had dipped further – the Human Development Index (HDI) value was 0.448 and life expectancy had dropped to 43.4years.

Worse still, the Human Poverty Index-1 (HPI-1) value was put at 40.6, ranking Nigeria 76th among 102 developing countries for which the Index had been calculated, and 160th out of 172 countries’ probability of not surviving past the age of 40years [21]. The HPI-1 measures severe deprivation in health by the proportion of people who are not expected to survive age 40 and represents a multi-dimensional alternative to the $1 a day World Health Organization (WHO) poverty measure. It also focuses on the proportion of people below a threshold level in the same dimensions of human development as the Human Development Index – living a long and healthy life, having access to education and a decent standard of living [21].

With these stark realities staring our developing nation in the face, something more realistic than the routine protocols needs to be employed in order to make neurosurgical care more readily available to the greatest number of our population. And the earlier this is employed the better and safer for all concerned. Since trauma is a largely preventable disease, policy makers need to elevate the priority level of safe road use beyond its present rating to make a positive impact on our health care delivery. It gives great hope, looking at previous results from other countries like Italy and United States of America, that if we intensify our efforts towards reducing the incidence of trauma, most of our youths, the most active and productive age group, and the future leaders of our country, would be spared, and of course, our abysmally low average life expectancy of 43.4years could improve for the better [18,20].

Our findings also make a point for the re-prioritization of our service delivery and resource disbursement to pay more focused and effective attention to the patients requiring trauma care whose numbers are massive and prognosis mostly good, and then pay relatively less attention to the less frequently encountered neuro-pathological conditions like neoplasms, craniofacial dysmorphisms, etc. This suggestion does not in the least imply that these other disease conditions should be ignored; rather, that their priority rating in terms of service delivery, in situations where human and material resources for specialist care are severely limited, should be properly re-positioned.

Under such circumstances, it may be wiser to install computed tomography facilities in all neurosurgical centres, which would be optimally satisfactory for trauma care, cheaper to maintain and ensure a more equitable distribution, while confining the installation of the more tasking and expensive magnetic resonance imaging to fewer designated centres in order to efficiently re-distribute available scarce resources. We may best be left with the option of referring the rare “once-in-a-while” cases to these designated centres where the incidence rates are higher and service expertise (which usually gets better with regularity of exposure to such cases), would be optimal. This would be the ultimate prelude to sub-specialization by both the neurosurgeons and the neurosurgical centres in our country.

Closely related to this is the urgent need to train more neurosurgeons and ancillary paramedical Staff to combat the challenge of trauma in our tertiary health facilities. More neurotrauma specialists, nurses, anaesthetists, intensivists, radiographers and interventionsts should be trained, and also, more trauma units and centres and better ambulance services with efficient communication and response co-ordination should be put in place to ensure the optimum care of these trauma cases and reduction of the mortality rate. Opportunities for fellowship training in neurotrauma should be sought and sponsored in reputable centres round the world to improve the knowledge base and management skills of already trained local neurosurgical personnel in the care of this major but preventable cause of morbidity and mortality.

Next to the significance of trauma is the burden of hydrocephalus – unexpectedly the second most common indication for neurosurgical treatment in our centre. Ventriculo-peritoneal shunting and endoscopic third ventriculostomy, which hardware and technical skills are becoming more readily available and affordable nowadays, should be given priority attention in the protocols of new centres in the poor African countries. Unfortunately, this type of advocacy for a comprehensive patient/disease triage can only be efficiently coordinated if a national epidemiological data base is generated from multi-centre studies round the country. This is still lacking in our case, and is evidently long overdue.

If this study, like other published local studies, represent the real situation in our country and possibly, in some other developing countries where the available specialist manpower and equipment are grossly inadequate, it would be instructive that in establishing neurosurgical centres, the services should be structured to take cognizance of the local disease profile in order to deliver the optimum benefits to the greatest number of persons. Such structured programmes would also substantially improve the training and dexterity of ancillary health personnel, as well as the skill and experience of the neurosurgical Staff, in appropriate service delivery.

CONCLUSION AND RECOMMENDATIONS

In South-East Nigeria, trauma – mostly from road traffic accidents, remains the most important indication for neurosurgical consultations, constituting the main workload in our service. The best solution has been proven historically to be prevention, and as such, short and long term preventive measures should be instituted by the government to reduce the burden of road traffic injuries.
Short term measures would include the enforcement of the use of protective helmets by motorcyclists, use of seat belts by motor vehicle passengers and limits for the serum alcohol level among drivers of automobiles. Long term measures would include rehabilitation and reconstruction of roads, public enlightenment and establishment of traffic monitoring units on the highways.

Presently, there is every need to establish efficient emergency mobile services, education of the public on steps to be taken at accident sites to prevent re-injuries, continuing medical education especially for Staff of the Accident and Emergency Unit and private health facilities where majority of the patients first present, and government facilitation and sponsorship for the training of more neurosurgeons in neurotrauma.

Table 1: Age Distribution

Table 2: Diagnoses made on individual cases

Table 3: Duration of Admission

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6