Pakistan Journal Of Neurological Surgery
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Primary CNS Lymphoma in an Immunocompetent Patient: An Unusual Case Illustrating the Usual Problems Facing Brain Tumour Management in a Lower-Middle-Income Country
Get PDFPrimary central nervous system lymphoma (PCNSL) is a rare extra-nodal non-Hodgkin lymphoma (NHL). It primarily affects the immunocompromised but is rarely seen in immunocompetent individuals. The pitfalls in the healthcare system of lower-middle-income countries produce many obstacles, impeding timely diagnosis, timely treatment, and optimal quality of care. A 57-year-old immunocompetent, diabetic female presented with progressive generalised fatiguability, forgetfulness, and subtle behavioural changes for the last one and a half years. MRI revealed an area of gyri from dense post-contrast enhancement in the right posterior parietal region. Her symptoms kept aggravating with periods of partial remission as steroids were being administered. Reasons for delays in diagnosis and hence timely treatment include lack of primary care referral, conflicting neurosurgical opinion, and absence of multidisciplinary team management. A right posterior parietal parasagittal craniotomy was performed to excise the lesion. The patient was subsequently referred for adjuvant therapy. We use our patient's clinical journey to exemplify the structural barriers to providing optimal and timely care for brain tumour patients in a developing country. Primary CNS Lymphomas in immunocompetent patients are rare. Poor infrastructure and referral pathways contribute to delayed diagnosis. Lack of multi-disciplinary care owing to organisational issues is a major problem faced by brain tumour patients in a lower-middle-income country like ours. Brain tumour management requires a specialist multidisciplinary team approach to ensure timely diagnosis and optimal treatmen
The Influence of Epidural Steroids on Postoperative Pain and Hospital Stay in Patients Having a Single-Level Lumbar Discectomy
Get PDFObjective: In this study, we looked at how intra-operative epidural steroids affected postoperative pain and stay duration in patients with unilateral single-level lumbar discectomy.
Material & Methods: A randomized control trial was conducted at Ayub Teaching Hospital Abbottabad. Group A (n = 30) was given intraoperative epidural methylprednisolone, while group B (n = 30) was given normal saline only. The outcome was measured between the two groups in terms of postoperative pain (visual analog scale), time of mobilization, length of hospital stay, and duration to return to work.
Results: At discharge, the VAS score in group A was 0.40 compared to 2.4 in group B (p = 0.000). At 2 weeks follow-up, the mean VAS score was 1.10 in group A in contrast to 1.4 in group B (p = 0.001). Patients who received local epidural methylprednisolone were mobilized after an average of 1 day, stayed for an average of 1.16 days, and returned to work following 18.2 days, whereas patients in the control group were mobilized after an average of 1.2 days, stayed for an average of 1.86 days and returned to work following 25.9 days. An incidental Dural tear occurs in 2 cases.
Conclusion: Intra-operative epidural steroid is beneficial in reducing post-operative pain, hospital stay, and time to return to work. It allows early mobilization with enhanced recovery and few complications
Efficacy of Balloon Kyphoplasty in Compression Fractures of the Thoracolumbar Spine
Get PDFObjective: To study the Efficacy of Balloon Kyphoplasty in compression fractures of the thoracolumbar spine.
Material and Methods: This study was conducted on 95 patients with thoracolumbar wedge fractures from 2017 to 2022. Complete neurological examination and CT and MRI scans of the spine of all patients were done. All patients have been treated with a balloon kyphoplasty procedure. Data was collected on VAS score, SF-36 score, kyphotic angle and percentage of vertebral body destruction both preoperatively and post-operatively. Statistical analysis was done by using paired sample t-test.
Results: The mean age was 57 years. Males were 58.9% and females 41.0%. Osteoporosis was the cause of fracture in 90.5% and trauma in 9.4% of patients. VAS improved from 7.42 ± 1.24 to post-procedure 3.24 ± 1.51, P < 0.0001. SF-36 improved from 35.31 ± 17.4 to post-procedure 49.23 ± 19.2, P < 0.0001. Kyphosis angle restoration from 18.42 ± 7.41 to post-procedure 10.61 ± 6.32, P value < 0.0001. Percentage loss of vertebral height from 32.91% to postoperatively 17.64% (SD-17.2 and P < 0.0001). 10.5% of patients developed cement leakage and there is no leakage in 89.4%. The adjacent level fracture occurred in 4 patients.
Conclusion: Balloon Kyphoplasty is an effective procedure for thoracolumbar wedge fractures. It improves pain, activities of daily living, kyphosis angle improvement, and restoration of vertebral height
Relationship between Postoperative Dexamethasone Following Posterior Spinal Surgery and Surgical Site Infection
Get PDFObjective: Studies have shown that postoperative dexamethasone administration in patients in whom posterior spinal surgical interventions have been carried out reduces the postoperative pain and decreases the analgesia requirement. Our study aimed to find out whether the use of postoperative steroids in patients that had undergone posterior spinal surgical procedures led to an increased incidence of wound infections.
Materials and Methods: The medical data of 52 patients in whom posterior spinal surgical interventions had been performed were retrospectively analyzed. The patients were divided into two groups. In the first group, postoperative dexamethasone had been administered after spinal surgery, and in the second group, no postoperative dexamethasone had been given. The two groups were then compared for their association with postoperative surgical site infection.
Results: Forty-five patients were included in the group in whom postoperative dexamethasone was given. Six (13.3%) of these patients developed postoperative surgical site infections. None of the seven patients in the second group in whom no postoperative dexamethasone had been administered developed postoperative wound infection. The difference in infection rate between the two groups did not reach statistical significance (p = 0.3).
Conclusion: An infection rate of 13.3% in the group of patients in whom postoperative dexamethasone had been administered is considerably high as compared to the 1 – 2% incidence quoted in the literature for simple laminectomy procedures. A prospective study with a larger sample size is needed to accurately define the relationship between postoperative dexamethasone administration and surgical site infection following posterior spinal surgery
Management of Calcium, Vitamin D, and Uric-Acid Levels for Spinal Pain
Get PDFLow back pain is incredibly painful and demoralizing due to the physical restrictions it causes as well as the psychological ramifications it brings. The calcium and alkaline phosphatase were favorably connected with vitamin D. The issue of low back discomfort presents a difficulty to healthcare practitioners. In developing nations, the problem is exacerbated by a failure to report for early treatment, vocational compulsions in rural regions, and sedentary lifestyles among urban youngsters 1. In Pakistan, there was a significant incidence of vitamin D insufficiency, with 53.5 percent of residents studied being vitamin D deficient, 31.2 percent being inadequate vitamin D, and just 15.3 percent having normal vitamin D (25-hydroxyvitamin D) levels. High levels of Vitamin D insufficiency were also seen, regardless of the various quantities of sunlight in the five city sites 2. In observational studies, consumption of carbonated beverages has been linked to an increased risk of fracture. The most common reason is that one or more of the beverage ingredients raise urine calcium. 3 There is a role of optimized levels of calcium, vitamin D & uric Acid in order to treat patients with low backaches. 1,4 The over intake of carbonated caffeine drinks and artificial fruit juices adversely impacts the proper absorption of vitamin D and calcium. Hence, good doses of supplements of Vitamin D and Calcium should be optimized for patients reporting muscles and joint pains. Severe back pain and lower extremities weaknesses have been reported in altered levels of vitamin D and uric acid. 5 We strongly recommend early and regular screening for vitamin D, Calcium, and uric acid as part of a comprehensive health assessment for low back pain
Outcome of Topical Epidural Methylprednisolone Versus Control in Lumbar Disc Surgery Patients
Get PDFObjective: The use of topical intraoperative methylprednisolone in lumbar disc surgery leads to significant improvement in pain relief and early resumption of daily life activities. The study determined the outcome of topical epidural methylprednisolone.
Materials & Methods: 60 patients included with diagnosed cases of the herniated lumbar disc with ASA Grade 2 and below. Group A was for patients who had to receive topical methylprednisolone while group B was the control group where no topical methylprednisolone had been used. The outcome was measured from OLBI and VAS scores. Results: In Group A, the mean hospital stay was 2 days, mean OLBI score was 35%, mean VAS score was 3, mean time to resumption of ADL was 7 days, mean dose of paracetamol (per day) was 3 mg, mean dose of Ketorolac (per day) was 90 mg. Whereas Group B, mean hospital stay was 3 days, mean OLBI score was 45%, mean VAS score was 5, mean time to resumption of ADL was 10 days, mean dose of paracetamol (per day) was 4 mg, mean dose of Ketorolac (per day) was 100 mg. In Group A, 91% of patients had a favorable outcome and 9% of patients had an unfavorable outcome. Whereas in Group B, 83% of patients had a favorable outcome and 15%of patients had an unfavorable outcome. There existed insignificant results in outcomes concerning diabetic/non-diabetic, and hypertension/non-hypertension. Conclusion: The use of topical intraoperative methylprednisolone in lumbar disc surgery leads to significant improvement in pain relief and early resumption of daily life activities as compared to without the use of topical methylprednisolone.
Keywords: Outcome, Epidural Methylprednisolone, Lumbar Disc Surgery, OLBI (Oldenburg Burnout Inventory), ADL (Activities Of Daily Life)
Frequency of Incidental Durotomy during Surgery for Degenerative Lumbar Spine Disease
Get PDFObjective: One of the most common treatments performed in a neurosurgical facility for lower back pain and claudication is degenerative lumbar spine surgery. The study aimed to determine the frequency of incidental durotomy during surgery for degenerative lumbar spine diseases.
Materials and Methods: In this study, a total of 95 patients were included from the Department of Neurosurgery, Ayub Teaching Hospital, Abbottabad. After the patient’s selection, their history, examination, and investigations, surgery was carried out by consultant neurosurgeons. Per-operatively unintentional dural tears were identified as rent in dura with or without CSF leak and were either repaired primarily or by applying fibrin glue if the repair was not possible.
Results: The mean age was 38 ± 12.62 years. Fifty-eight percent of patients were male and 42% of patients were females. More than 6% of patients had incidental durotomy while 94% of patients didn’t have incidental durotomy. Recurrent disc prolapse was found in 5% of the cases. One percent of incidental durotomy patients were also recurrent instances, accounting for 6% of the total. Whereas 95% of patients did not require a durotomy, the surgery went smoothly.
Conclusion: The frequency of incidental durotomy was 6% during surgery for degenerative lumbar spine diseases.
Keywords: Incidental durotomy, Degenerative Lumbar Spine, Spinal Stenosis, Spinal Surger
Results of Lumbar Transpedicular Fixation for Spondycolisthesis, in Terms of Back Pain Relief
Get PDFObjective: The goal of this study was to see how transpedicular fixation for degenerative spondylolisthesis affected lumbago.
Methodology: A retrospective observational study was conducted at the Department of Neurosurgery in Hayatabad Medical Complex, Peshawar between May 2018 and February 2020. Degenerative spondylolisthesis was diagnosed using static and dynamic spinal X-rays. The research excluded the patients with grade 5 spondylolisthesis, congenital anomalies, or prior spinal surgery. The visual rating scale was used to assess pain alleviation (GRS). Dynamic or static lumbosacral X-rays and 3D CT scans were used to assess union.
Results: In total 70 patients, 38 (54.3%) were male and 32 (45.7%) were female. L5–S1 was impacted in most of the cases (68%). 40% of patients were having Meyerding grade II. All patients had pedicle screw fixation. Following surgery, 44 (63%) patients reported no pain, and 12 (17%) patients reported mild discomfort. 8 (11%) patients reported moderate pain and 6(9%) patients experienced severe pain. There existed a significant difference between pre/postoperative moderate-severe GRS scores (p-value: 0.000336). After surgery, we were able to negotiate surgical unions with 91.4% of the patients.
Conclusion: For individuals with spondylolisthesis who need pain relief, transpedicular fixation is a safe, straightforward, and effective treatment. It also aids with the surgical union and the improvement of the neurological condition.
Keywords: Spondylolisthesis, Meyerding grading, Transpedicular fixation
Surgical Outcome of Spinal Tuberculosis Regarding Pain, Neurological Deficit, and Spinal Instability
Get PDFObjective: The most prevalent type of skeletal TB, which accounts for nearly half of all cases, affects the spinal column. Regarding pain, neurological deficit, and spinal instability, the study sought to determine the surgical outcome of spinal tuberculosis.
Material and Methods: This study was conducted in the Department of Neurosurgery, Ayub Teaching Hospital. A total of 42 patients with ages ranging from 24 – 66 years were included in the study. Information about the patient was gathered to determine indications (neurological impairments) about the ASIA Grading Scale and frequently affected areas.
Results: Commonest location was a thoracolumbar junction in 42.8%, followed by the lumbar spine in 23.8%. The pain was found in all subjects. The main indication of surgery was neurological deficit which is seen in 57% of patients followed by spinal instability or deformity in 16.6% of patients and patients with failed chemotherapy in 4.7% of patients. The preoperative KA was between 30 – 60º with a mean of 43.06 ± 4.11 degrees and 9.45 ± 3.99 degrees for postoperative KA (p-value < 0.0001). Most fixations of the cord were done through a posterior approach that was in 83.3% of patients. The neurological improvement according to ASIA grading was seen in 95.2% and no improvement was seen in 4.7% of patients upon 3 months follow-up.
Conclusion: Surgical treatment of the caries spine improves pain, lowers neurological compression, and successfully reverses deformities like kyphosis, resulting in better clinical results. It also helps to remove the Tuberculous burden from the body