Evaluating Low Back Pain Patients for Prolapsed Interverbral Disc in a Kenyan Teaching Hospital

Background Accurate evaluation of low back pain is essential for its rational management. The extent of use of clinical and imaging findings in identification of prolapsed intervertebral disk varies between centers. In Kenya, the diagnostic procedure is obscure. Objective To assess the evaluation of low back pain patients for prolapsed intervertebral disk at Kenyatta National Hospital, a teaching and referral hospital in Kenya. Study Design A retrospective chart study Patients and Methods Historical, physical and imaging findings of patients who presented with low back pain and subsequently diagnosed with prolapsed inter-vertebral disk between Jan 1997 and December 2007 were evaluated. Results Of the six hundred and three patients (267 males, 336 females) who were evaluated, risk factors were recorded in 39.5% patients, 35.3% patients had sciatica while straight leg raising test was performed in 52.2% patients. Investigations performed in these patients included plain roentograms (38.5%), CT scan (9.1%) and MRI (44.1%). Conclusion The evaluation of low back pain for prolapsed inter-vertebral disk was incomplete. History of sciatica, SLRT, crossed SLRT and MRI use are recommended for routine evaluation of low back pain for PID

Anomalous origin of left testicular artery from an additional renal artery

Gonadal arteries arising from additional renal arteries present an important variation that should be noted in order to avoid inadvertent injury to these vessels in renal hilar dissection and retroperitoneal surgery. During routine dissection, we observed the unusual origin of the left testicular artery from an additional renal artery in a middle-aged male cadaver. The prevalence of variations in the origin and course of the testicular artery displays population differences. Though additional renal arteries have been reported in literature, cases of such vessels giving rise to gonadal vessels are scarce. The possible embryologic basis for this variation as well as its clinical significance are discussed.Key words: Variations, renal arterie

Common carotid intimal medial thickness in a Kenyan population

Carotid intimal medial thickness, a marker for early atherosclerosis, has high clinical utility. It shows gender, regional, age and ethnic differences but data from black African populations are scarce. This study describes the carotid intimal medial thickness in a black Kenyan population. One hundred and fifty histological samples from 25 males and 25 female left common carotid arteries were routinely processed for light microscopy and stained using Mason’s Trichrome stain. The intimal medial thickness was measured on the photomicrographs using the Scion Multiscan software. The mean age of the cases was 28+19yrs. Mean carotid intimal medial thickness is higher in males (0.97+0.22) than females (0.77+0.06), p=0.05 and increases distally. Carotid intimal medial thickness increased with age being 0.5+0.16mm, 0.87+0.24mm and 1.21+0.36 mm for the age groups 0-20yrs, 21-40yrs and 41-60yrs respectively (p=0.035). Carotid intimal medial thickness in black Africans is similar to that reported for Caucasian populations. It is higher in males, increases distally and with age.Keywords: Carotid Intimal medial thickness, atherosclerosi

Surgical anatomy of the profunda brachii artery

Variations in the origin and termination of the profunda brachii artery (PBA) are rarely described in literature. Knowledge of this unusual anatomy is important during brachial artery catheterization and harvesting of lateral arm flaps. One hundred and forty four arms from 72 cadavers of black Kenyans were dissected and examined for the origin and termination of PBA at the Department of Human Anatomy, University of Nairobi, Kenya. The patterns of origin and termination of the PBA were observed and recorded. The PBA was present in all the cases. It arose from the brachial, axillary and a common stem with the superior ulnar collateral arteries in 96.9%, 1.4% and 1.7% of the cases respectively. It displayed duplication and early branching in 11.1% and 16.7% of the cases respectively. The high incidence of duplication and early branching makes it vulnerable to inadvertent injury during fractures of the humerus, brachial artery catheterization and may complicate lateral arm flaps. Preoperative angiographic evaluation is therefore recommended.Key words: Profunda brachii arteries, variations

Periduodenal Tuberculosis masquerading as Annular Pancreas

Gastrointestinal tuberculosis is common in Africa. Nonetheless, isolated  duodenal involvement is rare, and is more likely to mimic other causes of duodenal obstruction. We report a patient who succumbed to an isolated mid duodenal tuberculosis, diagnosed at laparatomy, whose clinical presentation, endoscopy and computerised tomography scans resembled annular pancreas. The limitations of clinical evaluation, endoscopy and radiology are highlighted as the importance of diagnostic laparoscopy is emphasized

Regional Topography of the Internal Carotid Artery

We studied the extra cranial portion of the internal carotid artery and structures associated with it, which are vulnerable to iatrogenic injury during surgical approach to the neck region in 18 individuals. Distances from the origin of the artery to hypoglossal nerve and posterior belly of digastric muscle were measured. The mastoid process and the hyoid bone were also used as landmarks in locating the nerve and respective distances measured. Hypoglossal nerve and posterior belly of digastric muscle crossed the ICA at variable positions with a mean distance of 10.1mm and 17.9mm respectively from the common carotid bifurcation. From the mastoid process, the internal carotid artery ascends underneath the posterior belly of the digastric muscle a third the distance to the hyoid bone. The external carotid artery is located lateral to the internal carotid artery in 63.8% of the cases, posterior in 16.7% and anterior in 19.4%. The posterior belly of digastric muscle and its attachments are key landmarks in identifying the internal carotid artery and thus avoiding injury to vital neurovascular structures which may help structures, which may help, improve clinical outcomes during surgery.Keywords: internal carotid, topography, landmark

Reappraisal of the dimensions of the diaphragma sellae

Morphometric dimensions of diaghragma sellae influence the extent of instrumentation and tumour exposure in the hypophyseal fossa, and the degree of compression of visual fibres from an expanding pituitary tumor. The dimensions show inter-population variations but data from Africans is scarcely available in literature. We aimed to investigate the morphometric dimensions of diaghragma sellae in an adult Kenyan population. One hundred and forty wet open crania (96 males, 44 females) obtained from the Department of Human Anatomy, University of Nairobi were studied. The shape of diaphragma sellae was classified as round or elliptical (elliptical was further classified as coronal elliptical or sagittal elliptical). The sagittal and coronal dimensions of the sellae were also determined. The diaphragma sellae was round in 60% of cases, coronal elliptical in 34% and sagittal elliptical in 6%. It was significantly wider in females than males (10.26+2.61mm vs 8.37+1.82mm respectively), p= <0.05. It was also wider in the coronal than sagittal dimension (20.01+2.00mm vs 18.45+2.97mm) and this difference was statistically significant. The significantly wider diaphragma sellae in females may provide better tumor exposure during surgery and may protect the visual fibres from a suprasellar extension of an expanding pituitary tumour. On the other hand, the larger coronal than sagittal sellae dimension should be considered during instrumentation in the hypophyseal fossa to avoid inadvertent neurovascular injury.Key words: Diaphragma sellae, Morphology, Morphometr

Morphology of the mandibular condyle in a Kenyan population

Use of condylar prostheses in mandibular reconstructive surgery is increasing in Kenya. To retain functional capability, condylar prostheses have to preserve the form of the condyle. Although condylar shape and size have been shown to vary between populations, few studies of these have been done in Africans. This study aimed to describe the morphology of the mandibular condyle in a Kenyan population. Sixty three mandibles of African origin were used. Condylar shape was assessed from the anterior, superior and lateral aspects as per a scheme used by Wedel et al. (1978). Data collected were analyzed using SPSS v.17 for frequencies and represented using tables, charts and photographs. The commonest shapes were: slightly convex anteriorly (71.43%); oblong superiorly (73.02%); and convex laterally (80.16%). Only the lateral shape displayed sexual dimorphism, with 100% of females but 88.33% of males having the C1 (convex) shape. Asymmetry was found in 12 (19.05%) of the mandibles. Right and left condyles are similar in shape in most cases but the frequency of the convex lateral shape displayed sexual variation. The mandibular condyles of Kenyans were different in frequency of convex lateral and anterior shapes from condyles of other populations recorded in literature. These differences in morphology imply that condylar measurements cannot be generalized in the manufacture of condylar prostheses and have to be customized for the local population as well as for male and female condyles.Keywords: Mandibular condyle, shap

Maintaining excellence in teaching of human anatomy: University of Nairobi experience

Experience in maintaining excellence in teaching of human anatomy is important in informing strategies to mitigate worldwide decline in the level of knowledge of human anatomy among medical students and qualifying doctors. Factors responsible for the decline include reduction in teaching time, inadequate teachers and undermining of cadaver dissection. Measures to address these challenges have resulted in wide disparities in curriculum design teaching methods, number and composition of instructors. Inspite of the challenges, the Department of Human Anatomy of the University of Nairobi (UON) maintained excellence of teaching for over 40yrs. This article describes the teaching of anatomy at the UON with a view of elucidating the learning points from which other departments can learn. Analysis reveals that human anatomy is allocated 630hrs per year of which 350hrs are allocated to gross anatomy with 270hrs devoted to dissection. Although dissection has remained the cornerstone of instruction, it is combined with clinically oriented problem based instruction, use of prosections, diagnostic imaging, computer aided and small group learning. Teaching of gross anatomy is integrated with microscopic, developmental and neuroanatomy. The department runs and intercalated Bachelor of Science (B.Sc.) anatomy degree which is a reliable source of members of staff. Over 70% of the staff are surgeons. They are assisted by demonstrators drawn from trainee surgeons and young B.Sc. Anatomy graduates. Excellence in teaching anatomy can be maintained by reclaiming sufficient teaching time, combined dissection with contemporary methods of instruction, integrating gross, microscopic, developmental anatomy, neuroanatomy, involvement of clinicians in teaching, commencing training anatomy early and engagement of demonstrators.Keywords: Anatomy teaching, University of Nairobi 

Experience with Hirschsprung’s Disease at a Tertiary Hospital in Kenya

BACKGROUND: Hirschsprung’s disease presents unique characteristics in Africans. Previous literature has reported high complication rates. We examined our single-institution experience with Hirschsprung’s disease (HD) to evaluate outcomes related to the different phases of care. STUDY DESIGN: Records were reviewed for children with HD managed during the years 2002 to 2006. Morbidities and mortalities were evaluated in relation to the different phases of care. Categorical variables were compared using Chi-square analysis. SETTING: Kenyatta National Hospital (KNH) a teaching and referral hospital, Nairobi, Kenya. RESULTS: One hundred and twelve patients with clinical diagnosis of HD were evaluated. Eighty nine had histological confirmation of HD. Forty four (39%) were aged 30 days or below. Eighteen children were lost to follow up before definitive diagnosis while a further 14 were lost after colostomy formation (before definitive surgery). Fifty six patients underwent definitive surgery (between one day and four years). Two had singlestage surgery while the rest had Swenson (52) and Boley’s (2) endorectal pull-through after interim colostomies. Thirty nine of 69 patients (56.5%) developed complications related to colostomies or definitive care. Morbidity related to colostomy alone was 34.7% while that related to the definitive surgery was 64.8%. There were sixteen deaths. The mean time to reversal for patients with colostomies was 23+12 months. Colostomy duration of more than one year was associated with more complications, increased duration of hospital stay and overall length of management. CONCLUSIONS: This retrospective review of a single-institution experience with treatment for HD has demonstrated a morbidity rate similar to other centres but a mortality rate higher than in published literature. Only 39% of patients with HD present during the neonatal period in our environment. The long duration of colostomy is associated with complications, prolonged duration of treatment as well as significant losses to follow up. A single-stage repair may expedite care and reduce the colostomy morbidity