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Vol. 50, No 1-2, March- June 2007 ISSN 0031-1480 VOL. 50, NO 1-2, MARCH- JUNE 2007 Medical Society of Papua New Guinea Executive 2007 President: Mathias Sapuri Vice-President: Nicholas Mann Secretary: Sylvester Lahe Treasurer: Harry Aigeeleng Executive Member: Uma Ambihaipahar ACKNOWLEDGEMENT We are grateful to the Government of Australia through AusAID for providing funding for the publication of this issue of the Journal. The Editors Published quarterly by the Medical Society of Papua New Guinea Papua New Guinea Medical Journal ISSN 0031-1480 March-June 2007, Volume 50, Number 1-2 EDITORS: PETER M. SIBA, NAKAPI TEFUARANI GUEST EDITOR: DAVID A.K. WATTERS Editorial Committee F. Hombhanje G. Mola A. Saweri J. Vince Assistant Editor: Cynthea Leahy Emeritus Editor: Michael Alpers Email: [email protected] Web page: http://www.pngimr.org.pg Registered at GPO, Port Moresby for transmission by Post as a Qualified Publication. Printed by Moore Printing for the Medical Society of Papua New Guinea. Authors preparing manuscripts for publication in the Journal should consult ‘Information for Authors’ inside back cover. Papua New Guinea Medical Journal Volume 50, Number 1-2, March-June 2007 CONTENTS FOCUS ISSUE ON NEUROSURGERY EDITORIAL Don’t be afraid of neurological assessment and keep it simple D.A.K. Watters 1 Neurosurgery in Papua New Guinea: quo vadis? J.V. Rosenfeld, W.M. Kaptigau and Y.F. Xie 5 Why computed tomography is needed in Papua New Guinea W.M. Kaptigau, P. Umo and J.V. Rosenfeld 8 ORIGINAL ARTICLES A history of kuru M.P. Alpers 10 Skull trepanation in the Bismarck Archipelago D.A.K. Watters 20 Surgical management of spinal tuberculosis in Papua New Guinea W.M. Kaptigau, J.B. Koiri, I.H. Kevau and J.V. Rosenfeld 25 Space-occupying lesions in Papua New Guinea – the CT era W.M. Kaptigau and Liu K. 33 Big heads in Port Moresby General Hospital: an audit of hydrocephalus cases seen from 2003 to 2004 W.M. Kaptigau, Liu K. and J.V. Rosenfeld 44 Trends in traumatic brain injury outcomes in Port Moresby General Hospital from January 2003 to December 2004 W.M. Kaptigau, Liu K. and J.V. Rosenfeld 50 Open depressed and penetrating skull fractures in Port Moresby General Hospital from 2003 to 2005 W.M. Kaptigau, Liu K. and J.V. Rosenfeld 58 Monitoring traumatic brain injury in Papua New Guinea W.M. Kaptigau 64 Neuroprotection in traumatic brain injury: practical implications for Papua New Guinea and some research developments W.M. Kaptigau 67 CASE REPORTS Paraplegia in a 10-year-old child: case report S. Thomas, D.A.K. Watters and J.V. Rosenfeld 72 Through-and-through penetrating spear gun injury of the head: case report P. Mamadi and W. Seta 74 CLINICAL PRACTICE A practical approach to the management of head injuries in Papua New Guinea W.M. Kaptigau 77 The management of spine pathology in Papua New Guinea W.M. Kaptigau, P. Mamadi and I. Kevau 87 MEDLARS BIBLIOGRAPHY 91 PNG Med J 2007 Mar-Jun;50(1-2):1-4 EDITORIAL Don’t be afraid of neurological assessment and keep it simple The clinical presentation of neurological feel. These senses and abilities make us disease varies according to the site and what we are. We should be able to do them extent of the pathology. Many medical all without pain and with full power and students and doctors seem afraid of coordination. If not, there is something neurological assessment but really there is amiss. Either the afferent or efferent nothing to fear. We need to know the pathways are not working – or both. The answers to three main questions: where is pathology will be in the central or the it, what is it and who can treat it? Once they peripheral nervous system (somatic or have been answered we still need to ask if a autonomic). condition should be treated or not. Many do not require a surgical solution, or the surgical Headache solution is too drastic. Symptoms such as headache are This focus issue of the Papua New Guinea experienced in many conditions common to Medical Journal contains another editorial PNG, including malaria. However, headache which stresses the value of having a CT that is new but does not go away, headache (computed tomography) scanner, first in Port that is posterior or accompanied by neck Moresby, and then in other level-two stiffness, sounds immediately more serious hospitals (1). Though there is already a and warrants investigation. In many parts of private scanner, all the readers of this journal PNG investigation may be limited to taking know there are many pressing health needs the temperature, fundoscopy (to exclude and most of the citizens of Papua New papilloedema) and lumbar puncture (LP) (in Guinea (PNG) will have to be managed the absence of papilloedema). Skull X-rays without CT scanning – despite its obvious though worth taking are seldom helpful. benefits of defining the site and size of a Subarachnoid haemorrhage may be neurological lesion. We need to assess accompanied by a herald bleed and LP will patients clinically and follow our common show xanthochromia. However, the option sense. to diagnose it by CT angiogram and treat it by clipping a berry aneurysm is usually not Clinical assessment was important in available to most of PNG’s citizens. determining what was going on in kuru, a disease that attracted world interest (2). It is Convulsions also needed for every patient with a neurological problem or a neurological Convulsions in children that are not manifestation of a systemic disease. accompanied by fever or convulsions that are new in adults not known to suffer from Neurological assessment aims to discover epilepsy always warrant investigation. symptoms, elicit signs and determine Convulsions suggest pathology in the solutions. cranium and the best investigation is a CT scan. Symptoms Comorbid diseases The cardinal symptoms of neurological disease are headache, convulsions, Many diseases may affect the nervous disorders of balance, loss of vision or other system. Diabetes and HIV (human senses, loss of power and loss of sensation. immunodeficiency virus) are PNG’s Some neurological conditions will present emerging pandemics that will add to the with pain or paraesthesia, particularly those burden of neurological disorders. Diabetes that press on peripheral nerves or nerve principally affects the peripheral nervous roots. We feel, we move; we move, talk and system, damaging motor, sensory and swallow in a coordinated fashion; we see, autonomic nerves. HIV affects both the we hear, we taste, we smell, we touch and central and the peripheral nervous system. 1 Papua New Guinea Medical Journal Volume 50, No 1-2, Mar-Jun 2007 The site of the various lesions will determine paralysis, between upper and lower motor the symptoms and signs. neurone disease, should normally be straightforward. That tendon hammer may Signs be misplaced but most PNG doctors are skilled in using the bell of their stethoscope Loss of balance or some other appropriate object to test for hypo- or hyper-reflexia. Other reflexes, Neurologists make much of demonstrating including the anocutaneous reflex (S3,4) and subtle loss of balance and coordination by cremasteric reflex (L1), are elicited by having patients walk a straight line, testing scratching the appropriate skin with a needle. finger to nose accuracy, checking the integrity of the posterior columns with a tuning fork Where is it? and seeing if they fall down when they shut their eyes. These are wonderful clinical signs The above symptoms and signs should to elicit. Unfortunately most patients with enable you to know roughly where the lesion brain stem, cerebellar or posterior spinal cord is located. However, to expect a reasonable pathologies already have advanced lesions. synthesis and diagnosis some knowledge of The history of what happened first will tell anatomy is necessary. Power is at the front you where the lesion started. Sadly, of the spinal cord, sensation anterolaterally opportunities to diagnose early, treatable and proprioception at the back. The disease have usually been missed by the approximate course of the cranial nerves time the patient reaches a specialist. This inside and outside the skull help with was the case with the child who had diagnosing the site. rhabdomyosarcoma of the spine (3). What is it? Cranial nerves This question often cannot be answered If the brain stem or posterior cranial fossa without histology. As access to the lesion is involved cranial nerves may be failing to often requires neurosurgical skills many function. It’s simple to test them – with a doctors in PNG are limited to what can be little knowledge of anatomy you can work out inferred from the findings of a lumbar where a lesion might be according to which puncture and simple investigations such as nerves are working and which are defective. skull, spine and chest radiographs. The next No technology is needed to test the cranial stage would be a myelogram or a CT scan nerves other than possibly a working light to but these may be hard to obtain. The paper observe the pupils (II/III), uvula, pharynx on space-occupying lesions in PNG is one (IX,X) and tongue (XII). Loss of vision is often of the first to help answer the question – what not appreciated till late but the ability to is it? (4). We now know that tumours are examine the retina (with a dilated pupil) and more common than tuberculomas as a cause check eye movements (III,IV,VI) only requires of space-occupying lesions even if basic medical skills. tuberculosis is more treatable (4). We know that if a brain abscess can be diagnosed Loss of function quickly the mortality will be reduced from 40% to around 10%.
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