Cranial bony decompressions in the management of head injuries: Decompressive craniotomy or craniectomy?

Objective: Decompressive surgery is one of the available options in dealing with traumatic brain injury (TBI) when clinical and radiological evidence confirm that medical treatment may be insufficient. This can be achieved either by complete removal of the bone or by allowing it to float, but the indications and utility of these are yet to be resolved. This study examines the indications and outcome for both procedures.Materials and Methods: Review of all cases of bony decompression done at the Memfys Hospital for Neurosurgery, Enugu, Nigeria from August 2002 to May 2010. Prospectively recorded data of CT, MRI, operating room, clinics and wards were utilized.Results: There were 38 patients out of whom 35 were males and 3 females. The mean age was 36 years (range 15-80). The causes of the predisposing TBI were road traffic accidents (RTA) (79%), gunshot (10.5%), and assault (7.9%). Decompressive surgery was unilateral in 36 and bi-frontal in 2. Decompressive craniectomy with bone stored in anterior abdominal wall pocket was done in 8 patients and decompressive craniotomy with bone left in situ in 30. Of the latter, bone was unsecured and allowed to float in 13 and the craniotomy was lightly anchored with sutures in 17 patients. Surgery was performed within 24 h in 68.4% of cases. Mortality was 21.1% overall but was up to 25% in the more severely injured patients who had craniectomy.Conclusion: Bony decompression is useful in the management of head trauma. Careful selection of cases and appropriate radiological assessment are important and will guide decision for either craniotomy or craniectomy.Key words: Craniectomy, craniotomy, trauma flap, traumatic brain injur

THE DISINTEGRATION OF YUGOSLAVIA: A LESSON FOR NIGERIA

The prediction by some experts within the United States National Intelligence Council in a document entitled “Mapping Sub-Saharan Africa’s Future” predicting outright collapse of Nigeria as a nation state cannot be wished away. The study examined the factors that precipitated the disintegration of Yugoslavia and juxtaposed them with the past and present religious and socio-political state of Nigeria. The paper maintained that virtually all the factors that led to the break-up of Yugoslavia abound in Nigeria. These factors include deep seated inter-ethnic rivalries, religious intolerance, dearth of national integration, internal colonialism and deficiencies in Nigeria’s federal structure. The real danger is not even the possibility of the break-up of Nigeria into new states; this would not necessarily be a problem, but the collapse of Nigeria into utter chaos and manslaughter. The study recommended true fiscal federalism, constitutionalism, respect for sectionalism, national integration and the implementation of the resolutions of the 2014 National Conference as measures to checkmate the disintegration of Nigeria.  Article visualizations

The AU free movement protocol: Challenges in its implementation

One of the major pillars of the African Union is the integration of peoples and the ability for them to move freely from one member country to another, with the right to reside and practise their trade or profession. This aspect of integration found full expression in the Protocol to the Treaty Establishing the African Economic Community Relating to the Free Movement of Persons, Right of Residence andRight of Establishment, adopted in 2018. Upon operationalization, it will remove obstacles to the movement of people, capital and resources in the region and give expression to aspiration 2 of the African Union Agenda 2063. However, significant challenges lie on the path of its implementation. This article doctrinally reviews the protocol, looking at its prospects for promoting African integration and development, anticipates some of the problems that the protocol will face. It concludes with recommendations for achieving its lofty but desirable ends

Dominant hemisphere and upper cervical cord tumefactive multiple sclerosis in a Nigerian teenager initially misdiagnosed and managed

A 13-year old right handed Nigerian girl presented with eleven weeks history of progressive visual loss, three weeks right hemi-body weakness which progressed to quadriparesis, dysphasia, severe headache, tonic-clonic seizures, neck pain, vomiting and fever.Examination revealed Glasgow Coma Score (E4M6V2), expressive dysphasia and depressed mood. Visual Acuity was counting finger bilaterally. Neck was supple. She had global hypotonia, grade 3 hyper-reflexia and extensor Babinski bilaterally. Power was 0/5 in the right upper limb and right lower limb, 2/5 in the left lower limb and 4/5 in the left upper limb. Other examinations were unremarkable.Contrast enhanced brain MRI revealed three cystic ring enhancing masses at left fronto-parieto-occipital region, associated oedema, midline shift and C2-C4 intramedullary mass with cord oedema. The ring enhancement was incomplete towards the cortex.Following initial suspicions of cystic brain tumour with spinal cord metastasis, she had decompression biopsy. Histology was inflammatory lesion, clinically assumed to be from brain abscess. Failure of antibiotic treatment and the deteriorating neurology prompted mini-craniectomy and biopsy of the cyst wall. Final diagnosis was tumefactive multiple sclerosis. She was successfully managed with methylprednisolone. Follow-up clinical condition has been satisfactory.Keywords: TMS, cranial masses, multiple sclerosis, visual los

Histologically Confirmed Intracranial Tumors Managed at Enugu, Nigeria

Background: There is controversy about the global distribution of intracranial tumors (ICTs). The previous reports from Africa suggested low frequency and different pattern of distribution of brain tumors from what obtains in other continents. The limitations at that time, including paucity of diagnostic facilities and personnel, have improved. Objective: The objective of this study is to analyze the current trend and distribution of histology confirmed brain tumors managed in Enugu, in a decade. Methods: A retrospective analysis of ICTs managed between 2006 and 2015 at Memfys Hospital, Enugu. Only cases with conclusive histology report were analyzed. The World Health Organization ICT classification was used. Results: This study reviewed 252 patients out of 612 neuroimaging diagnosed brain tumors. Mean age was 42.8 years and male-to-female ratio was 1.2:1.0. Annual frequency increased from 11 in 2006 to 55 in 2015. Metastatic brain tumors accounted for 5.6%, and infratentorial tumors represented 16.3%. Frequency of the common primary tumors were meningioma (32.9%), glioma (23.8%), pituitary adenomas (13.5%), and craniopharyngioma (7.5%) (P =0.001). Vestibular schwannoma accounted for 1.2%. Meningioma did not have gender difference (P =0.714). Medulloblastoma, glioma, and craniopharyngioma were the most common pediatric tumors. About 8.7% presented unconscious (P < 0.001). There was no significant difference between radiology and histology diagnosis (P =0.932). Conclusion: Meningioma is the most frequent tumor with increasing male incidence, but the frequency of glioma is increasing. Metastasis, acoustic schwannoma, lymphoma, and germ cell tumors seem to be uncommon. Late presentation is the rule

Gynaecomastia, erectile dysfunction and subfertility from tramadol abuse in a protracted case of left tilbiofibula nonunion: A case report

Introduction: The abuse of tramadol is on the increase and has attained epidemic proportion globally. Tramadol, a synthetic opioid is frequently prescribed to manage moderate to severe pain. The aim of this case report is to highlight the possible rare side effects of tramadol abuse in an orthopaedic surgical patient.Case report: A 37 year old married school teacher who had left Tibiofibular nonunion resulting from a poorly managed Gustillo-Anderson IIIc tibio-fibular fracture in a road traffic crash about 7 years earlier with associated chronic pain, deformity and limb length inequality for which he started selfmedication with tramadol, escalating to 1.5grams per day over the 7 year period. He had two children but his wife had not conceived in the past six years and there was associated poor erection. Examination findings of dysfunctional and insensate foot, tanner stage IV bilateral gynaecomastia and a score of 10 out of 30 on assessment of erectile dysfunction using international index of erectile function (IIEF) questionnaire. Ultrasound report showed normal breast tissues and loss of normal testicular echotexture, high luteinising hormone level and low testosterone level. His rehabilitation included tramadol withdrawal therapy, below knee amputation and prosthetic fitting . At his six months follow up visit, he had improved IIEF score of 20, his hormonal levels had normalized, and his wife was pregnant.Conclusion: Prolonged use of high doses of tramadol is an uncommon cause of gynaecomastia, erectile dysfunction and subfertility essentially due to testicular atrophy and testosterone suppression. Clinicians should prescribe this medication with caution and adopt multimodal analgesia therapy in management of chronic pain