Cost-Effectiveness of Operating on Traumatic Spinal Injuries in Low-Middle Income Countries: A Preliminary Report From a Major East African Referral Center

Study Design:
Retrospective cost-effectiveness analysis.

Objectives:
While the incidence of traumatic spine injury (TSI) is high in low-middle income countries (LMICs), surgery is rarely possible due to cost-prohibitive implants. The objective of this study was to conduct a preliminary cost-effectiveness analysis of operative treatment of TSI patients in a LMIC setting.

Methods:
At a tertiary hospital in Tanzania from September 2016 to May 2019, a retrospective analysis was conducted to estimate the cost-effectiveness of operative versus nonoperative treatment of TSI. Operative treatment included decompression/stabilization. Nonoperative treatment meant 3 months of bed rest. Direct costs included imaging, operating fees, surgical implants, and length of stay. Four patient scenarios were chosen to represent the heterogeneity of spine trauma: Quadriplegic, paraplegic, neurologic improvement, and neurologically intact. Disability-adjusted-life-years (DALYs) and incremental-cost-effectiveness ratios were calculated to determine the cost per unit benefit of operative versus nonoperative treatment. Cost/DALY averted was the primary outcome (i.e., the amount of money required to avoid losing 1 year of healthy life).

Results:
A total of 270 TSI patients were included (125 operative; 145 nonoperative). Operative treatment averaged $731/patient. Nonoperative care averaged $212/patient. Comparing operative versus nonoperative treatment, the incremental cost/DALY averted for each patient outcome was: quadriplegic ($112-$158/DALY averted), paraplegic ($47-$67/DALY averted), neurologic improvement ($50-$71/DALY averted), neurologically intact ($41-$58/DALY averted). Sensitivity analysis confirmed these findings without major differences.

Conclusions:
This preliminary cost-effectiveness analysis suggests that the upfront costs of spine trauma surgery may be offset by a reduction in disability. LMIC governments should consider conducting more spine trauma cost-effectiveness analyses and including spine trauma surgery in universal health care.

Postoperative Pulmonary Complications in Complex Pediatric and Adult Spine Deformity: A Retrospective Review of Consecutive Patients Treated at a Single Site in West Africa

Study Design:
Retrospective review of consecutive series.

Objectives:
This study sought to assess the incidence, risk factors, and outcomes of pulmonary complication following complex spine deformity surgery in a low-resourced setting in West Africa.

Methods:
Data of 276 complex spine deformity patients aged 3 to 25 years who were treated consecutively was retrospectively reviewed. Patients were categorized into 2 groups during data analysis based on pulmonary complication status: group 1: yes versus group 2: no. Comparative descriptive and inferential analysis were performed to compare the 2 groups.

Results:
The incidence of pulmonary complication was 17/276 (6.1%) in group 1. A total of 259 patients had no events (group 2). There were 8 males and 9 females in group 1 versus 100 males and 159 females in group 2. Body mass index was similar in both groups (17.2 vs 18.4 kg/m2, P = .15). Average values (group 1 vs group 2, respectively) were as follows: preoperative sagittal Cobb angle (90.6° vs 88.7°, P = .87.), coronal Cobb angle (95° vs 88.5°, P = .43), preoperative forced vital capacity (45.3% vs 62.0%, P = .02), preoperative FEV1 (forced expiratory volume in 1 second) (41.9% vs 63.1%, P < .001). Estimated blood loss, operating room time, and surgery levels were similar in both groups. Thoracoplasty and spinal osteotomies were performed at similar rates in both groups, except for Smith-Peterson osteotomy. Multivariate logistic regression showed that every unit increase in preoperative FEV1 (%) decreases the odds of pulmonary complication by 9% (OR = 0.91, 95% CI 0.84-0.98, P = .013). Conclusion: The observed 6.1% incidence of pulmonary complications is comparable to reported series. Preoperative FEV1 was an independent predictor of pulmonary complications. The observed case fatality rate following pulmonary complications (17%) highlights the complexity of cases in underserved regions and the need for thorough preoperative evaluation to identify high-risk patients.

COVID-19’s Impact on Neurosurgical Training in Southeast Asia

Objective: Neurosurgery departments worldwide have been forced to restructure their training programs due to the coronavirus disease 2019 (COVID-19) pandemic. In this study, we describe the impact of COVID-19 on neurosurgical training in Southeast Asia.

Methods: We conducted an online survey among neurosurgery residents in Indonesia, Malaysia, Philippines, Singapore, and Thailand from 22 to 31 May 2020 using Google Forms. The 33-item questionnaire collected data on elective and emergency neurosurgical operations, ongoing learning activities, and health worker safety.

Results: A total of 298 out of 470 neurosurgery residents completed the survey, equivalent to a 63% response rate. The decrease in elective neurosurgical operations in Indonesia and in the Philippines (median=100% for both) was significantly greater compared with other countries (p <.001). For emergency operations, trainees in Indonesia and Malaysia had a significantly greater reduction in their caseload (median=80% and 70%, respectively) compared with trainees in Singapore and Thailand (median=20% and 50%, respectively, p <.001). Neurosurgery residents were most concerned about the decrease in their hands-on surgical experience, uncertainty in their career advancement, and occupational safety in the workplace. Most of the residents (221, 74%) believed that the COVID-19 crisis will have a negative impact on their neurosurgical training overall.

Conclusions: An effective national strategy to control COVID-19 is crucial to sustain neurosurgical training and to provide essential neurosurgical services. Training programs in Southeast Asia should consider developing online learning modules and setting up simulation laboratories, to allow trainees to systematically acquire knowledge and develop practical skills during these challenging times.

A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.

Awake Craniotomy in a Child: Assessment of Eligibility with a Simulated Theatre Experience

Background: Awake craniotomy is a useful surgical approach to identify and preserve eloquent areas during tumour resection, during surgery for arteriovenous malformation resections and for resective epilepsy surgery. With decreasing age, a child’s ability to cooperate and mange an awake craniotomy becomes increasingly relevant. Preoperative screening is essential to identify the child who can undergo the procedure safely. Case Description. A 11-year-old female patient presented with a tumour in her right motor cortex, presumed to be a dysembryoplastic neuroepithelial tumour (DNET). We had concerns regarding the feasibility of performing awake surgery in this patient as psychological testing revealed easy distractibility and an inability to follow commands repetitively. We devised a simulated surgical experience to assess her ability to manage such a procedure. During the simulated theatre experience, attempts were made to replicate the actual theatre experience as closely as possible. The patient was dressed in theatre attire and brought into the theatre on a theatre trolley. She was then transferred onto the theatre bed and positioned in the same manner as she would be for the actual surgery. Her head was placed on a horseshoe headrest, and she was made to lie in a semilateral position, as required for the surgery. A blood pressure cuff, pulse oximeter, nasal cannula with oxygen flow, and calf pumps were applied. She was then draped precisely as she would have been for the procedure. Theatre lighting was set as it would be for the surgical case. The application of the monitoring devices, nasal cannula, and draping was meant not only to prepare her for the procedure but to induce a mild degree of stress such that we could assess the child’s coping skills and ability to undergo the procedure. The child performed well throughout the simulated run, and surgery was thus offered. An asleep-awake-asleep technique was planned and employed for surgical removal of the tumour. Cortical and subcortical mapping was used to identify the eloquent tissue. Throughout the procedure, the child was cooperative and anxiety free. Follow-up MRI revealed gross total removal of the lesion.

Conclusion: A simulated theatre experience allowed us to accurately determine that this young patient, despite relative contraindications, was indeed eligible for awake surgery. We will continue to use this technique for all our young patients in assessing their eligibility for these procedures.

The Influence of Cervical Spondylolisthesis on Clinical Presentation and Surgical Outcome in Patients With DCM: Analysis of a Multicenter Global Cohort of 458 Patients

Study design: Ambispective study with propensity matching.

Objective: To assess the impact of cervical spondylolisthesis (CS) on clinical presentation and surgical outcome in patients with degenerative cervical myelopathy (DCM).

Methods: A total of 458 magnetic resonance images (MRIs) from the AOSpine CSM-NA and CSM-I studies were reviewed and CS was identified. Patients with DCM were divided into 2 cohorts, those with CS and those without, and propensity matching was performed. Patient demographics, neurological and functional status at baseline and 2-year follow-up were compared.

Results: Compared with nonspondylolisthesis (n = 404), CS patients (n = 54) were 8.8 years older (P < .0001), presented with worse baseline neurological and functional status (mJOA [modified Japanese Orthopaedic Association Assessment Scale], P = .008; Nurick, P = .008; SF-36-PCS [Short Form-36 Physical Component Score], P = .01), more commonly presented with ligamentum flavum enlargement (81.5% vs 53.5%, P < .0001), and were less commonly from Asia (P = .0002). Surgical approach varied between cohorts (P = .0002), with posterior approaches favored in CS (61.1% vs 37.4%). CS patients had more operated levels (4.3 ± 1.4 vs 3.6 ± 1.2, P = .0002) and tended to undergo longer operations (196.6 ± 89.2 vs 177.2 ± 75.6 minutes, P = .087). Neurological functional recovery was lower with CS (mJOA [1.5 ± 3.6 vs 2.8 ± 2.7, P = .003]; Nurick [-0.8 ± 1.4 vs -1.5 ± 1.5, P = .002]), and CS was an independent predictor of worse mJOA recovery ratio at 2 years (B = -0.190, P < .0001). After propensity matching, improvement of neurological function was still lower in CS patients (mJOA [1.5 ± 3.6 vs 3.2 ± 2.8, P < .01]; Nurick [-0.8 ± 1.4 vs -1.4 ± 1.6, P = .02]). Conclusions: CS patients are older, present with worse neurological/functional impairment, and receive surgery on more levels and more commonly from the posterior. CS may indicate a more advanced state of DCM pathology and is more likely to result in a suboptimal surgical outcome.

Epidemiological Characteristics of Spinal Cord Injury in Northwest China: A Single Hospital-Based Study

Background: While the cities in China in which spinal cord injury (SCI) studies have been conducted previously are at the forefront of medical care, northwest China is relatively underdeveloped economically, and the epidemiological characteristics of SCI have rarely been reported in this region.

Methods: The SCI epidemiological survey software developed was used to analyze the data of patients treated with SCI from 2014 to 2018. The sociodemographic characteristics of patients, including name, age, sex, and occupation, were recorded. The following medical record data, obtained from physical and radiographic examinations, were included in the study: data on the cause of injury, fracture location, associated injuries, and level of injury. Neurological function was evaluated using the American Spinal Injury Association (ASIA) impairment scale. In addition, the treatment and complications during hospitalization were documented.

Results: A total of 3487 patients with SCI with a mean age of 39.5 ± 11.2 years were identified in this study, and the male to female ratio was 2.57:1. The primary cause of SCI was falls (low falls 47.75%, high falls 37.31%), followed by traffic accidents (8.98%), and impact with falling objects (4.39%). Of all patients, 1786 patients (51.22%) had complications and other injuries. According to the ASIA impairment scale, the numbers of grade A, B, C, and D injuries were 747 (21.42%), 688 (19.73%), 618 (17.72%), and 1434 (41.12%), respectively. During the hospitalization period, a total of 1341 patients experienced complications, with a percentage of 38.46%. Among all complications, pulmonary infection was the most common (437, 32.59%), followed by hyponatremia (326, 24.31%), bedsores (219, 16.33%), urinary tract infection (168, 12.53%), deep venous thrombosis (157, 11.71%), and others (34, 2.53%). Notably, among 3487 patients with SCI, only 528 patients (15.14%) received long-term rehabilitation treatment.

Conclusion: The incidence of SCI in northwest China was on the rise with higher proportion in males; fall and the MCVs were the primary causes of SCI. The occupations most threatened by SCI are farmers and workers. The investigation and analysis of the epidemiological characteristics of SCI in respiratory complications are important factors leading to death after SCI, especially when the SCI occurs in the cervical spinal cord. Finally, the significance of SCI rehabilitation should be addressed.

Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

Introduction
Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality.

Methods
A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded.

Results
Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6).

Conclusion
Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.

Emergency department management of traumatic brain injuries: A resource tiered review

Introduction
Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma.

Objectives
Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework.

Methods
A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings.

Key recommendations
Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.

A Case Report With COVID-19 During Perioperative Period of Lobectomy

Rationale: Currently, COVID-19 has made a significant impact on many countries in the world. However, there have been no reported cases of pulmonary lobectomy with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) infection. We are the first to report such a case.

Patient concerns: We report a 63-year-old Wuhan male patient with smoking history of 40 cigarettes per day for 40 years. He sought medical consultation for right lower lung nodules found by CT scan.

Diagnoses and interventions: The patient’s postoperative pathological diagnosis was squamous cell carcinoma of the right lower lung. On the fourth day after the operation, the real-time reverse transcription polymerase chain reaction test showed a positive result. After the operation, we routinely give symptomatic treatments such as anti-infection, nebulization and oxygen inhalation. We also change antibiotics several times depending on the patient’s condition.

Outcomes: The patient’s condition continued to deteriorate. On the fifth day after surgery, the patient died despite medical treatment.

Lessons: We are the first to report the diagnosis and treatment process of patients with COVID-19 during perioperative period of lobectomy. It provides a case for the postoperative management of such patients.