Pakistan Journal Of Neurological Surgery
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Clinical Outcomes of Dexmedetomidine As An Anesthetic Adjuvant in Intracranial Surgery, An Experience from Irfan General Hospital Peshawar: A Prospective Case Series Study
Get PDFObjective: Neuro anesthesia (most commonly general) is indicated in intracranial surgery, the goal of which is to maintain a stable hemodynamic environment. This study aimed at evaluating the effectiveness of Dexmedetomidine (DEX) when used as an adjuvant in intracranial surgery.
Materials And Methods: A prospective design was utilized and the data was collected at the Department of Neurosurgery Irfan General Hospital Peshawar in patients undergoing intracranial. All those patients having a score of 14 or 15 on the Glasgow Coma Scale, and I and II on the American Society of Anesthesiologists (ASA) undergoing intracranial surgery under general anesthesia were included in the study.
Results: The majority of patients were males 35 (66%) while 18 (34%) were females. 29(55%) patients were categorized as grade I while 24 (45%) as grade II according to the American Society of Anesthesiologists-Physical status. mean extubation time of our sample of patients undergoing craniotomy was 6.21 ± 2.16 minutes while the time for rescue analgesia was 41.23 ± 23.15 minutes. The heart rate values decreased significantly when noted at different intervals from the baseline.
Conclusion: Dexmedetomidine is an effective and safe anesthetic adjuvant when used in intracranial surgery and provides stable hemodynamics both intra and post-operatively. The neuro anesthetic drug also reduces the requirements of other opioids and rescue drugs
Frequency of Misplacement of Percutaneously Placed Pedicle Screws in Thoracolumbar Fractures
Get PDFof thoracolumbar fractures.
Material and Methods: A descriptive case series was conducted at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore. The study comprised all individuals who had minimally invasive percutaneously implanted thoracic or lumbar pedicle screws placed. CT scans were conducted on the patient 24 hours after surgery as part of their usual post-operative care to capture axial pictures to find Pedicular cortical breaches in any direction.
Results: Mean age of the patients was 32 years. 82.7% were male whereas 17.3% were females. We found that the frequency of misplacement was 10.9% in the management of thoracolumbar fractures. 110 patients received 600 pedicle screws placed percutaneously. Of these, 534 screws (89.1%) were ideally placed inside the pedicle. 7% showed minor pedicle penetration, 3.6% showed moderate pedicle penetration and only 0.3% showed severe penetration. Out of misplaced screws (10.9%), 7.3% of patients were between 15 – 40 years, and 3.6% were between 41 – 50 years. Out of misplaced screws (10.9%), 9.7% were male patients and 1.3% were female patients. For thoracic injury, 4.5% of patients suffered from misplaced screws, and for lumbar injury, 6.5% of patients were observed for misplaced screws (p-value: 0.008).
Conclusion: The frequency of misplacement was 10.9% in the management of thoracolumbar fractures. The misplacement rate of the percutaneously placed screw is low. Therefore, we concluded that the percutaneously placed screw is safe to use.
 
Radiological Verses Histological Evaluation of Spinal Space Occupying Lesions
Get PDFObjective: This study set out to evaluate radiology's diagnostic capacity in accurately establishing a preliminary working diagnosis for various spine tumor types.
Materials and Methods: This is a prospective study carried out and examined patients who had surgical resection with the collection of histopathology samples, regardless of age or gender. A full MRI examination from every angle and contrast-enhanced pictures were required. Inclusion criteria consisted of Patients of all ages of both genders, who underwent surgery a tissue sample was collected for histopathological diagnoses, and a complete MRI study with all views and contrast-enhanced images was available to give a preliminary diagnosis.
Results: Based on the evaluation by the senior radiologists, the lesions were most commonly intradural-extramedullary (50%) in position according to the dura, followed by intramedullary in 14 (26.9%) patients. Despite our series having a total of 16 misdiagnosed cases, the overall diagnostic accuracy of the MRI remained high at 69.2%.
Conclusion: MRI has superior diagnostic accuracy in diagnosing meningiomas as compared to nerve sheath tumors such as meningiomas. It also has good predictive accuracy of intramedullary lesions such as ependymomas
Assessment of Neuropsychological Impairment among Individuals with a History of Head Trauma – A Case-Control Analysis
Get PDFObjective: To determine the frequency of different neuropsychological impairments in traumatic head injury survivors compared to those without a history of head trauma.
Materials and Methods: A case-control study was done in Karachi, Pakistan, during February 2023 and March 2023, with participants aged 18 and above, of both genders, with or without a history of head trauma forming the case and control groups, respectively. Individuals with a history of head trauma or congenital neurological impairment were not included. Screening tools included the ESS, UNS, GAD-7 scale, and PHQ-9.
Results: A total of 303 participants were enrolled, out of these 128 (42.2%) were in the case group and 175 (57.8%) were in the control group. The most common source of head injury was Road Traffic Accidents (53.9%, n = 69). 143 (63.8%) out of 224 males had a positive history of head trauma in their lifetime, making the male gender more susceptible. The majority who had a history of head trauma lie in the age group < 21 years (52.6%, n = 110). No significant association was found between the interpretations of screening scales and history of head trauma.
Conclusion: Traumatic head injuries and their long-term consequences can predispose a person to experience any cognitive impairment in their life. However, in this study, we could not find significant neuropsychiatric deficits in patients with a history of head trauma. Therefore, it is crucial to conduct further large-scale, multi-center, and controlled studies to explore the cognitive and psychological impairment associated with head trauma
The Clinical Outcomes of Craniotomy in the Management of Cranial Arachnoid Cyst: An experience from Ali Institute of Neurosciences, Irfan General Hospital Peshawar: A Retrospective Case Series
No full textObjective: Intracranial arachnoid cyst is a non-neoplastic clinical entity that develops due to the splitting or duplication of the membrane surrounding the arachnoid matter. Nonspecific symptoms are usually treated conservatively. If the symptoms are severe, progressive, and disabling, surgical intervention is indicated. We aimed to evaluate the effectiveness and clinical outcomes of craniotomy in the management of arachnoid cysts.
Material and Methods: A retrospective case series study was conducted at Ali Institute of Neurosciences, Irfan General Hospital from the records of the past 8 years. Clinical records were analyzed. Thirty-six patients were included in our study as they were diagnosed as having symptomatic and progressive symptoms which required surgical intervention. In those patients, the standard procedure of Craniotomy was performed. Clinical and neuroimaging outcome scales were used.
Results: Mean age of the participant was 9 years at the time of surgery. Most of the arachnoid cysts were located in the temporal area 20 (43%), followed by post fossa 4(9%). The majority of the patients (63%) were characterized in COS 1 on the clinical outcome scale while there was no patient in COS 4 category. More than half of the patients (54%) had the cyst reduced to less than 50% of the original volume (NOS 2) while 25 percent of patients had the cyst size reduced but was still greater than 50% (NOS 3).
Conclusion: Craniotomy, an open surgical procedure is an effective intervention in improving clinical and radiological outcomes. However, it is also associated with significant recurrence rates along with other complications
The Swirl Sign and Its Relationship to Patient Outcomes in Extradural Hematomas: A Retrospective Investigation
Get PDFIntroduction:" Swirl sign" is a relatively uncommon sign, seen on non-contrast CT scans in patients with head trauma who develop extradural hematoma the prognostic significance of which is controversial. This research aims to evaluate the predictive significance of the swirl sign in patients with an extradural hemorrhage.
Material and Methods: It was a retrospective study and included 145 patients, with traumatic brain injury, who underwent surgical treatment at the Department of Neurosurgery Holy Family Hospital, Rawalpindi, Pakistan, between January 2022 and January 2023 and had traumatic EDH identified by computed tomography scan. Patients who did not undergo surgery or had combined or open craniocerebral injuries were eliminated. A Glasgow Outcome Scale score was used to evaluate outcomes after three months of traumatic brain injury. Mann-Whitney U test, the Chi-square test, and multivariate logistic regression were applied for descriptive and inferential analysis.
Results: A total of 145 cases were evaluated, 19 (13.1%) demonstrated the sign on a CT scan of the brain. Analysis displayed a notable association between the incidence of the swirl sign and pupillary size, preoperative Glasgow Coma Scale score, time between trauma and first CT scan, and volume of hematoma measured intraoperatively. Patients displaying the swirl sign showed an increased mortality rate (25%) compared to patients without the swirl sign (5%) and worse outcomes at 3 months.
Conclusion: The presence of the swirl sign on the CT scan had a significant association with worse outcomes. Early detection and prompt surgical evacuation are important for patients with this sign
Outcomes of Conservative Management of Acute Subdural Hematoma at GCS 15/15 in Post-Traumatic Patients
Get PDFObjectives: We observed the results of conservative care of acute subdural hematoma at GCS 15/15 in patients with a head injury from a car accident (RTA).
Material and Methods: It is a comparative observational study of 15 patients with presented to NS -2 Punjab Institute of Neurosciences (PINS), Lahore. Presenting complaints of patients were loss of consciousness, vomiting, headache, ENT bleeding, etc.
Results: The age range was 10 – 70 years. The mean age was 40 years. Conservative management was given to all patients for 10 days except 2 patients. All patients were advised to take complete bed rest for 3 weeks. We advised head ends elevation of all patients up to 15 – 30 degrees to lessen intracranial pressure. Anti-epileptic, mannitol, antibiotics, and acetazolamide were the medication that was given. Our 4 (26%) were hypertensive. Their blood pressures were monitored regularly and kept in the range of 140 – 160 mmHg so that the hematoma may not expand. Our 2 (13%) patients had DM and their BSR levels were monitored and consultation was also done from the diabetes clinic. Our 2 (13%) patients had a headache, and vomiting and which did not resolve so we had to operate on the patients. Midline shift in CT brain was ? 5 mm.
Conclusion: Acute subdural hematoma at GCS 15/15, midline shift was less than 5 mm, and thickness on plain CT brain was greater than 1 cm is best treated by medical management except in 13% of cases
Burnout and Ways to Reduce It among Postgraduate Residents of Neurosurgery
Get PDFObjective: The objective of the study was to know the rate of burnout and to explore the potential means to reduce burnout among neurosurgery residents.
Methods: This mixed-method explanatory sequential study was conducted at the Neurosurgery department of Lady Reading Hospital, Peshawar from July to September 2021. In the first phase of the study, burnout was assessed in postgraduate residents of Neurosurgery and its relationship with different demographic factors (quantitative). In the second phase focus group discussion with the residents were conducted to explore the ways to reduce burnout in residents (qualitative).
Results: 23 residents participated in the study. Burnout was found in 17 (73.9%) residents. The relationship between different demographic factors with burnout was not statistically significant. The results of the FGDs showed that the reasons behind burnout are; more workload, decrease interaction with the seniors, extra burden on trainees, conflicts with patient’s attendants, increased entries in the HMS system, wrong referrals from the periphery, decrease security of doctors in high-risk areas and lack of ownership by the seniors. The postgraduate residents suggested different ways to reduce burnout; including proper security of residents and all the staff, appreciation of the performance, peripheries should be developed and functional, SOPs for every part of the training should be advised, and proper training of the ancillary staff.
Conclusion: The majority of the neurosurgery residents were burnout and there is no statistically significant difference between different demographic factors related to burnout. This study also provided preliminary ways to reduce burnout among neurosurgery residents
Incidence of Post-Operative Cerebrospinal Fluid Leak in Patients Operated for Spinal Dysraphism
Get PDFfor spinal dysraphism.
Materials and Methods: 80 patients who underwent surgery for spinal dysraphism were enrolled in this study. This study was conducted at Neurosurgery Unit, JPMC, Karachi. Patients from 1 month to 3 years of age were included in the study. Patients were followed for 2 months post-surgery. The incidence of cerebrospinal fluid leak among patients operated for spina bifida was determined.
Results: Mean age was 1.5 years ± 5 months. There were 68.7% males and 31.3% females. 47.5% of patients had myelomeningocele, 41.3% of patients had meningocele, and 11.25% of patients had Tethered cords. Among 80 patients, 16.3% developed CSF leaks. 6.3% of patients were those who developed postoperative hydrocephalus and their CSF leak resolved after the VP shunt. In 8.8% of patients, CSF leaks resolved after suturing the leak area. 1.3% of patients with CSF leak developed meningitis; he was kept on antibiotics and was discharged on the 10th day of readmission. 5% of patients developed wound infections, they were kept on antibiotics, and daily dressings and were discharged within a week.
Conclusion: Most common location for myelomeningocele and meningocele is the lumbosacral area followed by the thoracic and cervical regions. Overall, 28.6% developed complications. 16.3% of patients developed CSF leaks.CSF leak was seen more in myelomeningocele repair patients as compared to meningocele and tethered cord. Most of the leaks can be managed with simple suturing and VP shunts in patients complicated by postoperative hydrocephalus.
Keywords: Myelomeningocele (MMC), Meningocele, Cerebrospinal fluid leak (CSF), VP Shunt
Anterior Lumbosacral Myelomeningocele Presenting as an Abdominal Mass
Get PDFMyelomeningocele is a complex pathology associated with variable clinical presentations and associated anomalies. Myelomeningocele presenting as an abdominal mass is extremely rare. This case report presents such a complex case of anterior lumbosacral myelomeningocele with clinical presentation of abdominal mass along with its surgical management. A 5-month-old boy was referred to the neurosurgery department, presenting with a congenital lump on his lower back along with abdominal mass, constipation, and urogenital dysfunction. An anterior Approach exploratory laparotomy was performed by a left lower abdomen oblique incision to excise the myelomeningocele. This case report illustrates that anterior lumbosacral myelomeningocele can present, in rare cases as abdominal mass along with urogenital dysfunctions and constipation and is managed with a collaborative effort from a multidisciplinary approach including urologists, neurosurgeons, and general surgeon