Cauda equina syndrome: As published in the Nigerian Journal of General Practice, Vol 9, No 02, November 2011

CAUDA EQUINA SYNDROME: Case report of a neurosurgical emergency

Biodun Ogungbo, Cedarcrest Hospitals, Garki II, Abuja, Nigeria

Thomas Russell, Western General Hospital, Edinburgh, United Kingdom

Corresponding author:

Dr Biodun Ogungbo MBBS, FRCS, FRCS, MSc, Consultant Neurosurgeon.

Email: ogungbo@btinternet.com 

Phone: 00-234-7082350074

Abstract

We present a young woman with symptoms and signs of cauda equina syndrome. Early surgical intervention led to improvement and restoration of sphincter function. The case serves to refresh our minds about this clinical entity.

Case report

A 37-years old woman was admitted to the Western General Hospital, Edinburgh as an emergency following a referral from her general practitioner; with a 4 day history of sudden onset of severe low back pain. This pain had progressively worsened over the few days. On the morning of admission, she woke up with the pain radiating down both lower limbs associated with leg weakness. She also noticed perineal sensory loss and bladder dysfunction. She could not feel the stream of flow through her urethra.

On examination, she walked with an antalgic gait and had reduced range of movement of her lumbo-sacral spine with tenderness to touch. Straight leg raising (SLR) was 30° with positive Lasègue's sign and sciatic stretch test bilaterally. She had normal objective muscle power in all muscle groups in the lower limbs. The knee jerks were heightened and the ankle jerks were depressed. She had reduced sensation to touch and pin prick from S1 to S4 dermatomes in the perineum.

An urgent MRI of her lumbosacral spine revealed a large L5/S1 central disc prolapse compressing the cauda equine at that level (Figure 1)

Figure 1

Legend: Large L5/S1 central disc prolapse (arrows) on sagittal (left) and axial (right) MRI scan. There is significant encroachment of the disc into the spinal canal with compression of the sacral nerves

 

 She was prepared for theatre and had an emergency L5/S1 decompression and discectomy. She was catherised preoperatively, but post surgery her bladder sensation and sphincter function gradually improved. She had normal sphincter function at the time of discharge 5 days later. The leg pain and weakness had also improved significantly.

Discussion

Cauda equina syndrome (CES) is a clinical entity due to compression of the lumbo-sacral nerves. CES symptoms may have sudden onset and evolve rapidly or sometimes chronically. Low back pain may be the most significant symptoms, accompanied by sciatica.⁽¹⁾ Patients present with radicular pain which could be unilateral or bilateral. This is associated with numbness and weakness in the areas supplied by the nerves being compressed in the spinal canal. In addition, patients complain of perineal numbness and varying degrees of bladder or bowel (sphincter) disturbances. This could be associated with loss of anal tone, impotence and sexual dysfunction.⁽¹⁾

The syndrome could be complete or incomplete. Complete means full loss of bowel and bladder control with little chance of recovery. Incomplete CES means that there are evolving symptoms of bowel and bladder dysfunction without full loss of function. This is potentially reversible. This potential is why CES is a neurosurgical emergency. CES from lumbar herniated discs is considered the only absolute indication for surgery. It is considered a neurosurgical emergency with the outcome related to how quickly it is diagnosed and treated.⁽²⁾ MRI is usually the preferred investigation approach.

There are many possible causes of CES. The commonest cause is lumbar disc prolapse but it can be caused by epidural hematomas, tumours, trauma and infection. A percentage of patients present with symptoms of CES but without any radiological evidence of structural pathology on MRI scan. While some may have an alternative organic cause, there is a "functional" origin in many patients.⁽³⁾

Our patient presented with a large L5/S1 disc prolapse causing significant narrowing of the spinal canal and compression of the nerves. This caused bilateral sciatic pain, weakness of the muscles in the ankle, loss of ankle reflex, perineal sensory loss and problems with bowel and bladder sphincter function.

Surgical intervention is often required to decompress the cauda equina by removing the compressing element. Most authors recommend a wide decompressive laminectomy when surgery is performed.⁽²⁾ If performed emergently this could lead to complete restoration of function and full recovery. Patients who have had complete CES are difficult to return to a normal status.⁽¹⁾ In a young patient, this could be very devastating. The results of recovery of bladder function are felt by many authors to be related to early diagnosis and surgical intervention.

Conclusion

The incidence and prevalence of CES has not been evaluated in the Nigerian population. This is an area worthy of research. The constraint of lack of easy access to MRI scans and affordability calls for adaptability and creativity in the diagnosis of CES in Nigeria. Early referral to the care of a neurosurgeon is critical and could be beneficial to the patient.⁽⁴⁾ Lumbar CT and CT myelography may be suitable radiological investigations as it is imperative that the diagnosis is made early and intervention offered in a timely fashion. This case report serves to remind us about this clinical entity.

References

1.            Ma B, Wu H, Jia LS, Yuan W, Shi GD, Shi JG. Cauda equina syndrome: a review of clinical progress. Chin Med J (Engl) 2009; 122(10):1214-22.

2.            Olivero WC, Wang H, Hanigan WC, et al. Cauda equina syndrome (CES) from lumbar disc herniations. J Spinal Disord Tech 2009; 22(3):202-6.

3.            Rooney A, Statham PF, Stone J. Cauda equina syndrome with normal MR imaging. J Neurol 2009; 256(5):721-5.

4.            Crowell MS, Gill NW. Medical screening and evacuation: cauda equina syndrome in a combat zone. J Orthop Sports Phys Ther 2009;39(7):541-9.

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SPINAL CORD INJURY:We can reduce the number of Nigerians living in wheelchairs
Posted By nigerianhealthjournal On October 12, 2011 (6:33 am) In Features, General Health, Health Promotion, Health Systems, Viewpoint

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With the right care, from the right specialist and at the right time, most Nigerians with spinal cord injury; now on wheel chairs or on sick beds may have been rescued and their conditions reversed. BIODUN OGUNGBO gives an insight into spinal cord injuries and surgical intervention that gives hope about the potentials of our health system and specialists to improve the quality of life for patients with spinal cord injuries.

In the past, farmers and palm wine tapers-who usually fall off trees, were the people who sustained spinal cord injuries. These days, road traffic accidents account for the majority. Many patients have been involved in accidents where the vehicle somersaults several times. The injuries occur often at the time of the accident or subsequently during extrication or transfer to the hospital.

Neck injuries resulting in damage to the spinal cord due mostly to road traffic accidents are common problems seen in emergency departments in Abuja. Reports suggest there is an increasing occurrence in other parts of the country. There are currently no firm statistics on the scale of the problem. Most patients present with partial or complete paralysis of the arms, the legs or both. This is because the spinal cord carries all the nerves that supply movement and sensation to the rest of the body. If the cord is severely damaged, the paralysis may be permanent. This includes loss of sexual function and loss of the ability to urinate or pass stool normally.

Image showing cervical spine injury,source: Biodun Ogungbo

Spinal cord trauma is damage to the spinal cord that eventually affects every part of the body. Good outcome depends on prompt and effective care from moment of injury and throughout the life of the paralysed person. In the developing countries, including Nigeria, there is still high morbidity and mortality rate as a result of inadequate facilities and care.

In the past, most patients with neck injuries in Nigeria were managed conservatively (without operative intervention). This was because of the paucity of experts trained in managing such injuries, lack of specialised equipment and of course the high cost of treatment. The cost in managing a paralysed person includes the hospital bills, costs of a carer to look after the person, loss of income and long term rehabilitation costs. This could easily run into millions of Naira. There are also significant material and emotional costs.

Prevention is Cheaper than Cure
I got into a taxi cab recently to travel a short distance. I usually sit in front and with the seat belt fastened. On this day, the driver said, ‘Oga, no need for seat belt, na short distance we dey go’.(meaning, sir, you DO NOT need the seat belt, we are ONLY going a short distance).  “So you think I’m confident in your driving?”, I asked as I make to adjust the seat belt. He laughed, nodded his head in understanding and promptly put on his own seat belt. When I seat in front like this, I am also driving with the driver, watching the road and cautioning about care on the road and the need to observe speed limits. It is the least you should do. Wear a seat belt, drive carefully and be cautious, wary of other road users. Do not let anyone drive you crazily (this includes public and private vehicles). It’s your neck.

Initial Care of the Spinal Injured

Preventing road accidents like this would reduce cases of spinal cord injuries in Nigerian especially in Abuja with an increasing rate of ghastly road accidents.

Spinal cord injury with paralysis is often associated with lifetime morbidity, so early active management is crucial. The initial care of patients with acute traumatic lesions of the neck (cervical spine) is of paramount importance. Neurologic function at both the nerve root and cord levels can be adversely affected by excessive motion of the unstable spine. Many of the patients in Nigeria have been moved from different hospitals before treatment. Most patients in a report from Enugu, Nigeria, 69 (66.4%), were received from private hospitals after a mean duration of 7 days. This increases the related morbidity and mortality. Ideally, treatment should start at the site of trauma. Safe and careful extrication, safe transportation and immobilisation in solid neck braces are crucial. It is known that following neck trauma, in-line stabilization using a hard cervical collar reduces movement of the cervical spine. These patients cannot and should not be moved without adequate protection and care.

Airway management and maintenance of spinal immobilization are important factors in limiting the risk of secondary neurological injury. Patients with spinal cord injuries may have difficulty with breathing due to this and other injuries such as head or chest trauma. Early effective and efficient management is crucial to survival. Transporting patients to hospitals with the capability to manage these cases is vital and information about these hospitals should be widely available. In Abuja, the only hospitals capable of managing head and neck trauma are Cedarcrest Hospital and the National Hospital, Abuja. One problem I have noticed is that there is little communication or cooperation between these hospitals. This is in spite of efforts to stimulate better working relations between the hospitals. The National Hospital for instance will not refer to Cedarcrest Hospital for obscure health management policies. Primus Hospital may also be able to manage these cases, if they have the necessary experts available on ground. Otherwise, they will preach transfer of the patient to India!

Diagnosis
Early diagnostic and clinical evaluations are important in determining the severity of the injury and making plans for subsequent management. Timely and appropriate imaging studies using x-rays, CT and MRI scans are essential to the cervical spine evaluation. Hospitals must be able to offer early neurological evaluation, investigation, diagnosis and surgical management to the majority of patients.

Management, manpower and resources
Research conducted in 2009 by a group of  orthopaedic surgeons at the Department of Surgery University of Calabar and University of Calabar Teaching Hospital, revealed that spinal injuries occur to young and active persons in their adolescence or early adulthood. But despite the frequent occurrence of this, the sad thing is that Nigeria has inadequate man power and equipment to treat accident victims diagnosed with neck and spinal injuries. We do not also have enough hospitals to treat the patients. The three National Orthopedic Hospitals (NOH) in Nigeria, namely, National Orthopedic Hospital, Igbobi, Lagos, National Orthopedic Hospital, Enugu and National Orthopedic Hospital, Dala-Kano, lack adequate equipment and the expertise to treat the ever increasing number of patients that report daily to the hospitals.
Despite the fact that the National Hospitals cannot perform the required surgeries, they continue to accept patients instead of referring them to appropriate hospitals where they can get help early. This situation, contributes to the complications of patients, since operation on spinal injury needs to be performed within the shortest time of the accident. Such complications include pneumonia, bedsore, hyperpyrexia, urinary tract infections, and respiratory difficulty and early death.

Because of the inadequacies of the hospitals and equipments to perform the operations and rehabilitation, it has become very expensive to treat patients with this kind of condition. This is why many patients with spine problems get abandoned by their relatives because they could not afford the cost of treatment. Many families also take their patients home, where many of them later die.

Early Surgical Management
Rafeal Ode, 31, suffered a neck injury following a road traffic accident. He was paralysed immediately due to damage to his spinal cord. He was recovered from the scene of the accident and transported to hospital in good condition. There he underwent an operation within hours, which removed the pressure on his spinal cord. Six weeks later, he was able to walk with the aid of a nurse and using a walking support frame.  “I spent over two million before I could get myself partially back to shape. My doctor said I was lucky, because my spinal cord was not badly damaged due to proper handling at the scene and the operation I got immediately,” he said. However, many Nigerians who have similar problems like this may not be so lucky, especially if they are poor-the reason why many are bed ridden for life while others die due to complications from the injuries. We have successfully operated on more than 30 spinal cord injury patients since 2009 with encouraging results. Some have improved beyond expectation and some remained permanently paralysed. A few have died as a result of their injuries or complications as discussed above. Of course, some have also died directly due to the operative intervention.

Conservative Management of Cervical Spinal Instability
Patients and their families have to pay for all investigations, operative interventions and acute care: the cost of a CT scan examination (CT spine) is uniformly about N40, 000 ($250 approximately) and MRI is double that (average monthly salary in Nigeria is about N20, 000 or $120 approximately). The operation cost about N1 million (One million Naira or equivalent of $6250 on average). The cost is therefore challenging for the average Nigerian. In this regards, conservative management remains a viable alternative and is often practiced. Management such as hard cervical collar, skull traction, Minerva jackets and plaster casts are sometimes used. The halo fixator has a well defined place in the management of fractures of the cervical spine. Available evidence suggests that management of upper cervical spine fracture with halo fixator is safe and effective. It is also however unavailable and unaffordable for most Nigerians.

Rehabilitation
Prolonged survival has resulted from better understanding of the pathophysiology of cord damage, as well as from the advances in antibiotic and ventilatory therapy. Regional spinal injury centers have done much to increase the survival of and quality of life of cord injured patients. Rehabilitation is also very important whether the patient has been operated or not. The importance of the role of post-injury rehabilitation cannot be over emphasised. The establishment of rehabilitation centres would go a long way in improving the social rehabilitation and survival of the patients. Some patients travelled abroad for rehabilitation. This cost on average about N20 million for 3 months of rehab. We have yet to see the benefit and that money could be better spent creating similar units here in Nigeria. There is need to congregate these patients in spinal rehabilitation centres where dedicated experts and facilities exist for improving the outcome of treatment through physical and mental rehabilitation.

You Need to know the following Facts:
The high morbidity associated with spinal cord injury could be reduced through public enlightenment on road safety measures and personal awareness. You cannot be too careful. We need to establish or refurbish spinal and trauma centres that are equipped to function. Improved outcomes can be achieved with a careful approach and multidisciplinary integrated care including improvements in intensive care and effective rehabilitation centres. This report should be a template for stimulating better understanding, care, early surgical treatment and efficient rehabilitation for this group of patients in the country as a whole.

Finally, you guessed right, I am an advocate for early surgical management.

Dr.Biodun Ogungbo is a Consultant Neurosurgeon at Cedarcrest Hospitals, Abuja and member,Editorial Board of the Nigerian Health Journal (NHJ).

©NIGERIAN HEALTH JOURNAL

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Article taken from Nigerian Health Journal - http://nigerianhealthjournal.com
URL to article: http://nigerianhealthjournal.com/?p=1447

CERVICAL SPONDYLOPTOSIS

Complete dislocation of the neck following trauma (Grade 4 Spondylolisthesis)

Road traffic accidents can sometimes lead to head and neck injuries. Neck injury can be mild as in whiplash injury, moderate or severe (with broken bones and spinal cord injury). Patients can present with varying degrees of damage to the spinal cord. Most patients present with partial or complete paralysis of the arms or legs or both. This is because the spinal cord carries all the nerves that supply movement and sensation to the rest of the body. If the cord is severely damaged, the paralysis may be permanent. This includes loss of sexual function and loss of the ability to urinate or pass stool normally.

The worst case scenario is the patient with complete dislocation (cervical spondyloptosis) and often complete damage to the spinal cord. Management is difficult and requires operative intervention. The operation is difficult and requires careful thought and efficient post operative care. The days following surgery are crucial and there must be really good attention to details and correction of physiological problems. Recovery is often poor with permanent paralysis. The impact on the life of the patient and family is unimaginable.

Example below: CT scan of the neck of a patient with complete C5/C6 dislocation.

Same case below: X-ray following surgery and anterior plating with bone graft

MRI scan below: Months later showing the area of complete spinal cord transection. 

There was no recovery of function below the level of injury

Large brain tumour: Meningioma

This pleasant 67 year old man was seen with a large right temporal brain tumour. The tumour had caused weakness of the left side of the body and he had also gradually become unconscious. He had been in another hospital for a month while awaiting transfer to India for treatment. The scan showed severe intracranial pressure and I felt that he would not survive the flight abroad. Clinically, he was neurologically debilitated and moribund. We admitted him and treated for a week on steroid therapy to reduce the intracranial pressure. We subsequently proceeded with surgery.   

The operation: Right temporal craniotomy and COMPLETE excision of the tumour. We also excised the involved dura mater and replaced with artificial dura. A post operation CT brain scan confirms complete excision. He has improved significantly since the operation and was discharged home in good condition.
 

Points to note: He was being managed in a hospital for weeks with a large brain tumour and significant raised intracranial pressure. The hospital had no neurosurgeon available and never bothered to refer him locally. They were keen to plan transfer to India. He would not have survived the flight.

The unknown fact is that many Nigerian patients with tumours and cancer are best treated here especially if the condition is severe. Many die on the way or soon thereafter. Of course, many are packaged and returned back home if no treatment can be offered.

Advice: It is always best to get an opinion from a specialist here first before traveling abroad. Use the ABUJA HEALTH CARE DIRECTORY to find a suitable and qualified specialist.
 

 Can you spot the tumour?

  

It is about half the size of the brain on the right side (on your left). The brain on that side has been compressed and its function impaired by the weight of the tumour.

.

Following the operation, the tumour is gone and the brain is re expanding.

Anterior decompression, fusion and plating in cervical spine injury: Early experience in Abuja, Nigeria

SUBMITTED FOR PUBLICATION
ABSTRACT

Aims and Objectives

We present a review of the results of the current surgical management of acute cervical spine injuries in the Federal Capital Territory, Abuja, Nigeria. This is the first detailed retrospective study on the surgical management of patients with cervical spine injuries from Nigeria.

Method

The medical reports of patients with traumatic cervical spine and spinal cord injuries undergoing surgery from 1st August 2009 till 30th August 2010 were reviewed. Management and early results of outcome were ascertained and detailed consecutively in a prospective Microsoft Office Access® database (Microsoft Group of Companies). Frankel grading was used for pre and immediate post operative evaluation (within 48 hours). The Barthel Index (BI) was used to classify patients as dependent or independent at follow-up.

Results

Twenty consecutive patients presented with acute cervical spine and spinal cord injuries since August 2009. 20 anterior cervical spine decompression and fixation with an iliac graft and an anterior cervical plate (ACDF) were performed in 18 patients. All operations were performed with general anaesthesia using standard techniques but without a microscope or a high speed drill. Of the 18 patients who were operated, 4 patients died within a short period following surgical intervention. 7 patients have made a full recovery and 7 remain fully dependent. Only two of the dependent quadriplegic patients have become reintegrated back into the society.

Conclusion

The management of spinal cord injuries in Abuja is evolving. The operations were performed adequately with much limited complement of equipment. The morbidity and mortality in this series is acceptable. Poor intensive care therapy is a major challenge and improvements in this area of care will likely lead to better patient outcomes.

Keywords

Trauma, Cervical Spine traumatic instability, Surgical fixation, Anterior cervical discectomy, Outcome, Nigeria

Comments:

The points to note is that these emergency operations can be performed in Nigeria to a satisfactory standard and achieving good results. Five of the patients went abroad (UK, SA and Beirut) for rehabilitation and none had to be re-operated by the reviewing neurosurgeons.

Patients with acute cervical spine injuries can be operated as soon as possible to decompress the spinal cord, re align the fractured bones and therefore ease them into rehabilitation early. Information is important and so YOU need to know that we have the facility to offer early intervention for your patients.

The days of bed rest for months while the doctor thinks about what to do are over, at least in Abuja. These operations reported here were performed safely with a minimum complement of equipments. We now of course, have additional equipments and have operated on many more patients who would be reported in the near future. 

Example below showing before and after surgery MRI scan images. The spinal canal has been opened up and the pressure off the spinal cord.

Another case: The chap had a complex fracture at C2/C3 and spinal cord contusion at C5/C6. He was operated at both levels with spinal screw fixation, anteriorly. Post operative image a few days later. On the right, in a wheel chair and active rehabilitation has commenced. He improved to walking and independent function within a few months after discharge to rehab in Gboko, Benue State. He is back to his previous employment.

This is what we are hoping to achieve in a consistent manner. Operating early allows the patient to go for rehab early and prevents bed sores, urinary/ chest infections, deep vein thrombosis, depression and early death.

‘Let’s diagnose accurately and restore confidence of Nigerians in their doctors’

Published.

September 15, 2011 By nigerianhealthjournal 1 Comment

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Austin Obichere,MD

“I was diagnosed with pneumonia and being treated for pneumonia until I got to London where I was told I had cancer of the lungs”. That was the story of Late Chief Gani Fawehinmi and indeed the story of many patients in this part of the world; and Austin Obichere, a Consultant Colorectal Surgeon at the University College London Hospital (UCLH) is concerned. He shared this concern with NIGERIAN HEALTH JOURNAL which led him to set up D&TEC (Diagnostic &Therapeutic Endoscopy Centre, Ikoyi, Lagos) which is the first purpose designed endoscopy suite in Nigeria offering world class endoscopy services. In 2003, Austin was appointed Hon. Senior Lecturer, University College London (UCL) in having completed specialist training in coloproctology at St. Mark Hospital London and Mount Sinai Hospital in Toronto.  He is a Joint Advisory Board (JAG) accredited bowel cancer screening colonoscopist and currently the Director Bowel Cancer Screening Programme at UCLH. He had also held the post of Chairman Colorectal Cancer Tumour Board HCA Hospitals, U.K. His area of specialist interest include laparoscopic colorectal cancer surgery, screening and surgical management of colorectal cancer along with other benign disorders of the gastrointestinal tract and pelvic floor.
What’s the attraction for you in medical diagnostics?
Accurate medical diagnosis with an emphasis on the word ‘accurate’ is critical before any doctor can begin to formulate a plan to successfully treat their patient. A good doctor given the tools at our disposal in modern medical practice should strive to make an accurate diagnosis in more than 90 percent of all cases.
What is wrong with our approach to diagnosing diseases in Nigeria?
It’s basically inability to make accurate diagnosis more frequently than not! I believe competent doctors are in abundance in Nigeria but they carry an “Achilles Heel” in that the necessary infrastructure / support services required are either none existent or at best rudimentary.  By these services one is referring to a triad of; a) Laboratory Services (inclusive of pathology services; b). Imaging services (Ultrasound scan, ct-scan, mri-scan, mammograms etc; c) Endoscopic services (ability to visualise any luminal structure or organs using flexible fibre-optic cameras).With these triad of services provided that they are quality assured, the clinician is empowered to make an accurate diagnosis in more than 90% of cases.
Can there ever be an acceptable justification for the high cost of medical diagnosis especially CD4 Count, Viral load tests, ECG and the likes?
The answer is a categorical NO! Because, you end up denying the vast majority of our population access to basic health services that should not be a privilege but the right of every Nigerian. The simple problem is that the expertise is lacking therefore demand exceeds supply-meaning that the few providers have a monopoly and thereby escalate prices. The fact is that the cost of these equipments/agents used worldwide for medical diagnosis is relatively cheap so what we need is training enough personnel with the expertise to provide these tests effectively and thereby bring down costs. In the case of cancer; for instance, cancer of the bowel, it is known that this is on the increase or has always been there, but we did not have the equipments or expertise required to diagnose it.  Furthermore, endoscopy services are critical to allow the doctor to directly visualise any part of the body not only to see the problem but also to take tissue samples to confirm diagnosis. This is standard practise all over the world but sadly is lacking in Nigeria in terms of availability of these service and paucity of the necessary expertise to deliver this essential arm required for accurate diagnosis.
Chief Gani Fawehinmi was wrongly diagnosed with pneumonia until he got to the UK where he was diagnosed with Cancer. Where does this place our healthcare system?
It places us at the very bottom on the League of Nations providing quality health care for their population. This in my view is the single most degrading aspect of modern day Nigeria given that many of our citizens have no other choice but to join the band-wagon of health migrants with significant contribution to foreign economies like India.
Is there anything synonymous with what you are doing and the clamour for evidenced-based care?
What we are doing is merely trying to address one aspect of the triad (Endoscopy) of services alluded to above. There is no greater evidence than to directly visualise a diseased organ at endoscopy, obtain appropriate tissue samples for confirmatory histology of the disease. In other words we are providing the evidence in the area of diagnostic endoscopy that will arm clinicians to deliver the right treatment based on “accurate diagnosis”. This is one small contribution D&TEC is making towards a quality service and hopefully, the eventual eradication of the TMD (Typhoid, Malaria Doctors) syndrome from our society.
Iam sure some would be interested in what the TMD Syndrome is all about?
The TMD syndrome refers to the fact that these are the only two diagnoses (typhoiod and malaria) that many doctors in Nigeria make when patients come to see them with an illness without thinking of other causes.
So what then is the contribution of improper diagnosis to the growing cases of medical accidents especially in Nigeria?

Gani:a victim of wrong diagnoses;a diagnostics centre has been dedicated in his honour by the Ondo State govt to avert wrong diagnosis ta least in the state.

The contribution is immeasurable! I am too embarrassed to even consider mentioning numerous personal experiences in my practice here in Lagos and the U.K. I have seen many Nigerians in my private practise in Harley Street who presented with bowel symptoms that were investigated in Nigeria and found to be normal. However, on repeating a colonoscopy I was surprised to find the presence of bowel cancer- indicating that the previous examination in Nigeria was either not complete or that the doctor did not have the necessary skills to complete the examination. There are also cases where patients have been told they have cancer only to discover after a repeat colonoscopy that there was no evidence of cancer. Sadly, I am not alone in these experiences and quality of Diagnosis was the subject of ridicule amongst my English colleagues. This was the catalyst that led to my setting up D&TEC.

Is there any close correlation between the problem of fake drugs and the quality of diagnosis?
I think we are dealing with two separate issues here in that fake drugs relate to attempts to treat what is often a flawed diagnosis resulting in “double jeopardy”. Firstly, the diagnosis is wrong more often than not, and secondly, you are receiving fake drugs that can lead to the demise of the patient concerned as we have seen from various cases in Nigeria.
Have you been able to evaluate your organisation’s contribution towards improving the quality of healthcare in Nigeria?
Yes; and one has to be careful not to appear boastful. However, at this point in time we have performed over 250 endoscopic procedures and 11 colon cancers diagnosed from nearly 150 colonoscopies, equating to 7 per cent


incidence within this small group that were screened at D&TEC. Many did not have a diagnosis until they arrived at D&TEC and more than half had advanced cancers that were not surgically treatable because they had either ignored the symptoms for too long or were treated for the wrong condition. On the other hand, 5 patients in the group with cancer have been successfully treated by surgery with excellent prognosis. I believe we have succeeded in not only raising awareness in the need to embark on preventive screening strategies but also demonstrated that D&TEC can provide that very same world class endoscopic service seen abroad right here on our doorstep in Lagos.
Recently, Dr. Okonjo-Iweala was quoted as saying that Nigerians spent about N300 Billion seeking for healthcare overseas. Does this give an indication of a business prospects for anybody like you interested in diagnosis…since it is a search for the best quality of care?
It certainly does! And just imagine how much the Nigerian economy would benefit if the very same amount of money is left within these shores rather than diverted to build up the economy of others. This is where I believe our government has an essential role to play using whatever resources are at its disposal to reverse this trend. They can start by changing the attitude of some state and Federal governments who think it is cool to send employees abroad for medical treatment. Imagine the uproar in the USA if Barack Obama had to travel to India to be treated for an ailment. The message is clear; our government has to assist/partner those who have a genuine desire from their actions to raise the standard of healthcare in Nigeria so that we can reverse health tourism.
And can you articulate the role quality diagnosis can play in turning the tide of medical tourism in our favour?
Accurate high quality diagnosis should be our “holy grail” as it is the single most important step in transforming the health care service in Nigeria from dependency on health tourism to independence. It is the critical building block in ensuring that our country can provide a health service comparable to the best in the world because we are already blessed with Nigerians who have expertise in all aspects of any comprehensive health care system. D&TEC, I would hope, is one’s small contribution towards the Holy Grail that hopefully will trigger many other similar ventures and restore the confidence of Nigerians in their doctors.
Interview  by Kingsley Obom-Egbulem
©NIGERIAN HEALTH JOURNAL

Comments

 

 

Biodun Ogungbo says:

September 16, 2011 at 1:00 pm

This article raises very important issues and I could not help but comment on it.
One of the reasons that Nigerians fail to trust doctors is in the area of misdiagnosis and the reasons are legion. Diagnosing pneumonia for cancer and calling cancer, TB, is all too common. I blame the radiologists. They blame the referring physician! The patient blames the doctor. We all blame each other till the pathologists arrive.
The key focus must be that we practice medicine to the very best of our abilities. Recognition of the limits of those abilities and limits/ extent of training is sometimes the key problem. There are elderly doctors who think they know best and continue to give outdated information and advice. There are young doctors who think they know best and perform beyond their level of experience.
This has been best summarised as below, in the levels of skill and consciousness: Where do you fit in on a daily basis? In respect of particular care, procedures and skill when treating patients.

Level 1: ground level: Unconsciously Unskilled
Level 2: next level up: Consciously Unskilled
Level 3: next level up: Consciously Skilled
Level 4: Highest level: Unconsciously Skilled

The unconsciously unskilled are the total novice and charlatans who do not know that they do not know anything. The unconsciously skilled are the experts who can operate without even thinking about it. It is the highest skill level. This does not necessarily equate to the consultant!!!!!

Recently, I attended a radiology conference and presented patients with CT and MRI scans misdiagnosed by radiologists. Most of the radiologists agree and one hopes that many would refrain from reporting on areas where they have little or limited knowledge. But, they did say that many referral letters fail to provide adequate information. Return them, I say, but its not that simple.

Again, only last week, I also attended a conference of the Ophthalmology Society of Nigeria to talk about patients with visual loss due to brain tumors, who have been misdiagnosed. Many of the patients were treated for refractory errors and given glasses for progressive blindness. They finally had huge brain tumors such as pituitary macroadenoma diagnosed. They should have been offered early neurological evaluations and CT or MRI scans. The optometrists and ophthalmologists were only interested in selling spectacles to theses patients and watch them go blind. The cost, morbidity and mortality related to treating these huge tumors is very high.

Is it the training that is deficient or the level of communication? Lack of communication? Is it mistrust? Is it greed?

But, what about patients who default and go off to traditional healers and faith healers in churches and mosques? What about those who present daily at the chemists and pharmacies asking to be treated by untrained people simply because it is cheaper. The treatment may then complicate the diagnosis and affect recovery.

So many issues and so many reasons.