Pakistan Journal Of Neurological Surgery
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The Availability and Utilization of Minimally Invasive Techniques (MITs), in Neurosurgery in Pakistan
Full text linkBackground: Minimally invasive techniques (MITs) have transformed the landscape of neurological surgery, offering a paradigm shift to patient safety, recovery speed, and surgical precision.
Objectives: This article explores the availability and utilization of these techniques, highlighting their benefits, advancements, and regional variations in practice. The primary goal of this study is to facilitate the adoption of advanced Minimally Invasive Techniques (MITs) in neurosurgery at hospitals in Faisalabad.
Methodology: A complete methodology, keeping the said purpose in mind, is designed to bring a pragmatic shift of advanced minimally invasive techniques in neurosurgery to the healthcare system of Faisalabad for improved patient care and surgical outcomes. A total of two District Headquarters Hospitals, DHQs, and two private hospitals are selected in Faisalabad. The sample of N=100 neurosurgeons, technicians, support staff
and hospital administrators selected randomly.
Results: The study revealed significant differences in the adoption and attitudes towards minimally invasive techniques (MITs) across public and private hospitals, with private hospitals showing higher adoption of advanced surgical methods. Factors such as equipment costs, training programs, and institutional support were key barriers influencing MIT utilization. The statistically significant differences in factors influencing MIT adoption underscore the need for targeted.
Conclusion: The study highlights that while both public and private hospitals show positive attitudes toward the adoption of MITs, various barriers such as high equipment costs, insufficient training, and lack of institutional support hinder widespread adoption. Public hospitals are more reliant on traditional surgeries, whereas private hospitals are leading the adoption of advanced surgical techniques
A Rare Presentation of Extradural Ewing Sarcoma in the Lumbar Spine: A Case Report
Full text linkIntroduction: Ewing sarcoma (ES) is the most prevalent malignant bone tumor in children and adolescents, mainly impacting the axial skeleton and long bones. Extradural manifestations of Ewing sarcoma, particularly in the lumbar spine, are rare and may pose diagnostic challenges. This manuscript describes an unusual case of an epidural lumbar region, Ewing sarcoma, presented with acute neurological symptoms.
Case Presentation: A 14-year-old male patient presented with a history of a fall resulting in paraparesis and urinary incontinence for the last 1 week. MRI revealed an extradural lesion compressing thecal sac at the L4-L5 level. An extradural hematoma or an ependymoma were the initial differentials, and intravenous steroids were commenced, resulting in partial relief of symptoms. Later on, a core needle biopsy and immunohistochemical staining were performed, confirming Ewing sarcoma with positive CD99 and vimentin. Surgical excision of the tumor was performed, achieving clear margins, and there was significant improvement in patient symptoms.
Discussion: Lumbar epidural Ewing sarcoma in the lumbar spine is unusual and can result in acute neurological symptoms, creating a diagnostic dilemma. This case report testifies to the significance of maintaining high suspicion and emergency action for extradural spinal tumors. A complete surgical excision confirmed the diagnosis and improved the patient's neurology.
Conclusion: Recognising a spinal tumor and swift treatment is vital to patient improvement, especially in acute cases. A delay can result in permanent neurological harm to the patient
Surgical Outcome of Brain Contusions Treated by Decompressive Craniotomy With or Without Lobectomy
Full text linkObjective: To compare the surgical outcomes of decompressive craniotomy with or without lobectomy for patients presenting with brain contusions in a tertiary care trauma center.”
methods: This randomized clinical trial was carried out in the Neurosurgery department, Allied Hospital, Faisalabad, for 1 year. Patients admitted with severe TBI were enrolled and underwent decompressive craniotomy (DC) with lax duraplasty, or decompressive craniotomy with lobectomy (DCWL) or contusionectomy and lax duraplasty
Results: The mean GCS score at presentation in DC was 5.8±0.755 and in DCWL was 5.64±0.74. At the 3rd month, 44% patients had GOS-E at vegetative state, 30% had GOS-E at lower severe disability, and 26% had GOS-E at upper severe disability in the DC group. But in the DCWL group, 2% patients had GOS-E at vegetative state, 22% were at lower severe disability 16% were at upper severe disability, 30% had GOS-E at upper moderate disability, and 30% were at lower moderate disability (P<0.05). At the 6th month, 26% patients had GOS-E at dead state, 34% were at upper severe disability, and 40% were at lower moderate disability in the DC group. But in the DCWL group, 38% had GOS-E at upper moderate disability, 32% were at lower good recovery, and 30% were at upper good recovery (p<0.05).
Conclusion: The surgical outcome of brain contusions treated by DCWL was better compared to DC without lobectomy
Micro-bleedings of Cerebrum and Leukoaraiosis: Magnetic Resonance Imaging-Based Correlation Analysis by Micro-Bleed Anatomical Rating and Fazekas
Full text linkObjectives: Using Fazekas and Micro-bleed Anatomical Rating Scales (MARS) to assess the inter-relationship of MB(C) and leukoaraiosis based on magnetic resonance imaging (MRI).
Materials and Methods: Cross-sectional observational research was carried out at the radiology department of RYK Hospital Rahim Yar Khan, Pakistan. The study involved 70 participants who had MRI brain scans and were discovered to have micro-bleeds. The Micro-bleed Anatomical Rating scale (MARS) was used to grade micro-bleeds and Fazeka’s scale was implied for grading leukoaraiosis. The relationship between MARS and Fazeka’s scale was ascertained by Spearman's correlation.
Results: The patient's mean age was 65 years and 2 months, with male to female gender ratio of 1.8:1. A significant correlation (p<0.001) was observed between micro-bleeds grading of MARS and Fazekas grades, with a significant correlation coefficient of 1. Cerebral micro-bleeds also correlated with coexisting diseases, notably hypertension (84.28%), diabetes (60.00%), and smoking (55.71%). MRI analysis showed micro-bleeds were most frequently in variable locations (44.6%), followed by lobar regions (27.7%), deeper areas (18.5%), and basal nuclei (9.2%).
Conclusion: Leukoaraiosis (LA) and MB(C) have a strong correlation that suggests micro-blood vessel ischemia and hemorrhage as ultimate outcomes
Frequency of Functional Outcome Among Patients with Spinal Tumor Visiting Tertiary Care Hospital
Full text linkObjective: To determine the frequency of functional outcomes among patients with spinal tumors.
Materials and Methods: This study was conducted at the neurological surgery department, Liaquat University of Medical and Health Sciences, Jamshoro and it was a descriptive study. A total of 145 patients presenting with spinal cord tumors were admitted through the outpatient department (OPD) and subsequently underwent surgical procedures. The diagnosis was primarily based on MRI findings, and the Frankel scale was used to assess neurological progress.
Results: The current study included 145 patients in total, with 65.5% of them being male. The majority (75.2%) were older than 60, whereas the mean age was 65.65±6.43 years. In contrast to the 15.9% of tumors in the cervical spine, 73.8% in the thoracic spine, and 10.3% in the lumbar spine, there were 13.8% intramedullary and 86.2% extramedullary tumors. Eight percent of patients required dorsal stabilization, 9.7% had surgical issues, 11.7% had medical difficulties, 66.2% required perioperative corticosteroid administration, and 11% required neuromonitoring. Upon admission, 11.7% had radiating pain, 34.5% had back discomfort, 82.1% had sensory deficiency, and 71% had bowel/bladder dysfunction. The mean McCormick score was 3.17±0.67 and 2.56±0.92 on admission and discharge, respectively whereas the mean KPS was 49.42±11.78 and 49.42±11.78 receptively. There were 40% of patients with unfavorable and 60% with favorable outcomes.
Conclusion: Early diagnosis with minimal symptoms leads to better outcomes, whereas delayed presentation and significant neurological deficits are associated with poorer prognosis
Comparative Analysis of MRI DWI/ADC Changes with Clinical Recovery in Stroke Patients
Full text linkObjective: To determine the relationship between MRI diffusion weighted imaging (DWI), apparent diffusion coefficient (ADC) changes, and clinical recovery in acute ischemic stroke patients.
Materials and Methods: This prospective observational study was conducted at the Radiology Department of Lady Reading Hospital, Peshawar, from January 2025 to June 2025. A total of 234 patients with acute ischemic stroke were included. All patients underwent MRI with DWI and ADC sequences within 24 hours of symptom onset. Clinical severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and functional recovery was evaluated using the Modified Rankin Scale (mRS) and Barthel Index at discharge and 30-day follow-up. Statistical analysis included Pearson correlation and multivariate regression to assess the association between imaging parameters and clinical outcomes.
Results: DWI reversal on follow-up imaging was observed in 38.6% of patients and was strongly associated with improved functional outcomes (p=0.002). Multivariate analysis confirmed baseline DWI volume, mean ADC value, and NIHSS score as independent predictors of recovery.Conclusion: DWI lesion size, ADC value, and initial NIHSS score are significant predictors of clinical recovery in acute ischemic stroke patients. Incorporation of MRI-based diffusion imaging in routine stroke assessment improves early prognostication and guides management decisions
Role of Intradiscal Gentamycin Wash on Incidence of Postoperative Discitis
Full text linkObjective: Postoperative discitis (POD) is a serious yet uncommon side effect of lumbar discectomy with long-term morbidity, delayed recovery, and high cost of treatment. Local prophylaxis is a viable alternative to systemic antibiotics, which fail to reach a therapeutic level in the avascular disc. This study sought to assess the efficacy of intradiscal gentamycin wash in the prevention of POD.
Material and Methods: A retrospective study was conducted on 160 patients (58% male) who underwent lumbar discectomy between December 2023 and January 2025. The patients were categorized into Group A (n=70), without intradiscal wash, and Group B (n=90), with intradiscal wash (gentamycin 80 mg). All were then clinically and radiographically followed for 12 months. The incidence of POD was the main outcome, and clinical, radiological, and laboratory characteristics were analyzed in patients with POD.
Results: POD occurred in 5 patients (3.1%). Group A had 4 cases (5.7%), whereas Group B had 1 case (1.11%), showing a significant reduction (p < 0.05; RR = 5.14). All POD cases were managed conservatively with intravenous administration of antibiotics, use of bracing, and analgesics, and they had full recovery within 6-12 months without surgery.
Conclusion: Intradiscal gentamycin wash is an easy, safe, and cost-effective adjuvant that has proven to be significantly effective in the reduction of POD after lumbar discectomy. Larger prospective trials are indicated to establish a role for its routine clinical use
Decoding Brain Metabolism: Diagnostic Accuracy of Magnetic Resonance Spectroscopy Versus Fluorodeoxyglucose Positron Emission Tomography in Neurological Disorders
Full text linkObjective: To compare the diagnostic performance of Magnetic Resonance Spectroscopy (MRS) and Positron Emission Tomography (PET) in the evaluation of brain metabolic disorders, with a specific focus on diagnostic accuracy, lesion detection, and metabolite quantification.
Materials and Methods: This prospective observational study was conducted at the Department of Radiology, Lady Reading Hospital, Peshawar, from January to July 2023. A total of 150 patients with clinical suspicion of brain metabolic dysfunction underwent MRS at LRH and PET at affiliated external centers. Imaging findings were independently interpreted by two radiologists. Diagnostic metrics were calculated, and statistical significance was determined using chi-square and independent t-tests.
Results: Lesion detection rates were 78.0% for MRS and 88.0% for PET. PET demonstrated higher sensitivity (88%) compared to MRS (78%), while MRS had slightly higher specificity (85% vs. 82%). Combined modality uses in concordant cases yielded the highest diagnostic accuracy (AUC = 0.93). Statistical analysis confirmed significant differences (p < 0.05).
Conclusion: MRS and PET offer complementary diagnostic capabilities. Their combined application enhances diagnostic accuracy and clinical confidence, especially in resource-limited or diagnostically challenging scenarios
One-Year Shunt-Free Survival after Secondary Endoscopic Third Ventriculostomy (ETV) for Shunt Malfunction: Insights from a Tertiary Care Center in a Resource-Constrained Setting
Full text linkObjectives: To assess the one-year shunt-free survival rate in patients undergoing secondary ETV for shunt failure.
Materials & Methods: This retrospective study is done to evaluate the one-year shunt-free outcomes of secondary endoscopic third ventriculostomy (ETV) in 32 patients who presented with ventriculoperitoneal (VP) shunt malfunction due to obstructive hydrocephalus in a tertiary care hospital. Post-operative clinical features of raised intracranial pressure and shunt malfunctions were assessed for one year. MRI or CT scan and a history of shunt revision/insertion during the follow-up period were also noted.
Results: We had 32 patients in our study 17 males (53.1%) and 15 females (46.9%) with shunt malfunction treated by secondary ETV. The mean age at the time of ETV was 12 years with standard deviations ranging from 0.7 to 15 years. The one-year shunt revision-free survival rate was 68.8%. No major complications occurred in patients after the endoscopic procedures.
Conclusion: Results show a significant success rate in achieving shunt-free outcomes, especially in younger patients, favoring, secondary ETV as a viable option as compared to shunt revision.
Keywords: Endoscopy, Hydrocephalus, Ventriculoperitoneal Shunt, shunt failure, Ventriculostom
Clinical Outcome of Microvascular Decompression In The Management Of Trigeminal Neuralgia In A Single Center: A Prospective Study
Full text linkObjectives: In the cases of trigeminal neuralgia unresponsive to medication or conservative measures, microvascular decompression is the preferred surgical technique. The objective of the current study was to evaluate the clinical outcomes of the microvascular decompression technique in the management of TN.
Material & Methods: This prospective, observational study spanned over two years from January 2021 to December 2022. Adults diagnosed with typical TN who were at least eighteen years old, and who were not responding to conservative treatment options, including carbamazepine and gabapentin, were enrolled in the study. The assessment of pain was performed using the Visual Analog Scale (VAS) and the Barrow Neurological Institute (BNI) pain intensity scale.
Results: The mean age of the patients was 52.4 ± 10.2 years, with a range from 32 to 74 years.