Pakistan Journal Of Neurological Surgery
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Surgical Outcomes of Tethered Cord Release Under Intraoperative Neuromonitoring in Patients with Tethered Cord Syndrome
Full text linkObjective: To analyze the efficacy of intraoperative neurophysiological monitoring (IONM) to keep the patient neurologically functional during surgical management of Tethered Cord Syndrome (TCS).
Material and Methods: The retrospective study was done on 40 patients of tethered cord release in Khyber Teaching Hospital, Peshawar, during March 2024 to February 2025. Transcranial motor evoked potentials (TcMEPs), tibial nerve somatosensory evoked potentials (TNSEPs), and pudendal anal reflex (PAR) were used as intraoperative monitoring. Pre and postoperative evaluations were done on motor strength, sensory, and bladder/anal control. The Fisher Exact Test was used to carry out statistical analysis with a p-value of < 0.05.
Results: The average time of follow-up of patients (mean age: 20.14 +/- 11.96 years) was 8.41 months. The success monitoring was 95 percent in TcMEPs, 72.5 percent in TNSEPs, and 82.5 percent in PAR. In 7.5 percent of cases, transient deficits were reported. TcMEPs had a sensitivity and specificity of 100 percent to predict motor outcomes. TNSEPs were highly correlated with sensory changes (p = 0.049), whereas PAR was not significantly correlated with bladder dysfunction (p = 0.497). There were no significant complications.
Conclusion: Multimodal IONM of tethered cord surgery promotes intraoperative safety and contributes to the maintenance of motor and sensory functions. TcMEPs were very accurate in the determination of motor outcome, whereas TNSEPs were very informative in the determination of sensory activity
Clinical Outcomes of Transforaminal Injection in the Management of Lumber Radiculopathy
Full text linkObjective: The objective of this study was to evaluate the clinical outcomes of transforaminal dexamethasone injection in patients with lumber radiculopathy.
Material and Methods: This one-year cross-sectional study was carried out at Afridi Medical Complex from February 2022 to January 2023. The included patients of lumber radiculopathy underwent a single dose of transforaminal dexamethasone injection under the guidance of a fluoroscope. The outcome measures including pain, disability, and mobility were assessed through VAS, RMDQ, and FTFD before, one month, and two months post-intervention.
Results: The study included 487 patients undergoing the intervention, the mean age of participants was 52.3. Following the injection, the mean leg pain score improved from a baseline of 8.2 ± 1.1 to 3.0 ± 0.8 (p < 0.001). One-month post-injection, it further decreased to 2.5 ± 0.7 (p < 0.001) and at two months to 2.0 ± 0.6(p < 0.001). When measured at baseline the mobility score of FTFD was 18.6 ± 4.5 cm which then improved to 11.2 ± 3.7 cm after one month and then to a further 7.8 ± 2.9 cm at two months (p < 0.001).
Conclusion: For those patients unresponsive to conservative treatment options including medication and physical therapy, transforaminal dexamethasone injection is a safe and effective intervention in terms of improvement in different outcome measures including pain, disability, mobility, and return to work
Clinical Determinants and Neurological Manifestation Among Adult Patients with Vitamin B Deficiency
Full text linkObjective: To assess the factors and neurological manifestations in adult patients with vitamin B12 deficiency.
Materials & Methods: A cross-sectional study was carried out at the Department of Neurology, Liaquat University of Medical and Health Sciences (LUMHS) for the period of Six months after the approval of the study from March 7, 2023, to September 6, 2023. The sample size was calculated using the WHO sample calculator, a total of 253 patients were enrolled. The data was obtained from patients fulfilling the inclusion criteria, and complete history and investigations were done on all the included patients.
Results: The study included 253 patients with a mean age of 46.9±11.5 years, of which 68% were male and 32% were female. Various neurological manifestations were observed among patients with vitamin B12 deficiency. The most common symptom was nerve numbness, affecting 65.2% of patients, followed by motor weakness in 24.1%. Non-traumatic compressive myopathy was found in 20.5% of patients. Other symptoms included ataxia (18.2%), impaired position sensation (14.2%), impaired vibration sensation (11.1%), and optic atrophy (3.9%). Signs of dementia were noted in 4.7% of cases. These findings highlight the diverse range of neurological symptoms linked to vitamin B12 deficiency and their varying prevalence.
Conclusion: It is to be concluded that a wide spectrum of neurological symptoms is associated with vitamin B12 deficiency, highlighting its potential impact on neurological health. Nerve numbness stands out as the most prevalent symptom, affecting a significant majority of patients, followed by motor weakness and non-traumatic compressive myelopathy
Patterns of Radiological Complications in Patients with Spondylodiscitis: A Retrospective Analysis from a Tertiary Care Hospital
Full text linkObjective: To analyze the demographics and other patterns associated with patients diagnosed with spondylodiscitis.
Methods: In this retrospective observational study, data from 96 patients diagnosed with discitis based on clinical and imaging findings at Lady Reading Hospital, a tertiary care center in Peshawar was reviewed. Data collected included demographic information, clinical presentation, and diagnostic imaging findings. Logistic regression analysis was used to assess risk factors, with results presented as odds ratios (OR) and 95% confidence intervals (CI).
Results: Among the 96 patients (57 males, 39 females; mean age 45.5 years), vertebral body involvement was observed in 56% of cases. Cord compression was noted in 36% of patients, significantly associated with advanced age (OR = 1.05; 95% CI: 1.02-1.08, p < 0.01). Decreased disc height was present in 65% of cases, correlating with higher risks of vertebral body abscesses (65%) and psoas abscesses (52%). The lumbar spine was the most commonly affected region, with multilevel involvement observed predominantly in older adults (p = 0.07).
Conclusion: The study highlights the high prevalence of complications in spondylodiscitis and emphasizes the need for timely diagnosis and intervention. These findings can guide improvements in clinical protocols to enhance patient care in low-resource settings
Clinical and Radiological Evaluation of Pediatric Leukodystrophies: A Prospective Study from a Tertiary Care Center in Pakistan
Full text linkObjective: To evaluate the clinical and magnetic resonance imaging (MRI) characteristics of pediatric patients with leukodystrophies and assess the diagnostic value of MRI in a low-resource setting.
Materials & Methods: This prospective observational study was conducted at the Department of Radiology, Lady Reading Hospital, Peshawar, Pakistan, between January and November 2024. A total of 165 children under 14 years of age with clinically suspected leukodystrophies were included. MRI was performed using a
1.5 Tesla scanner and interpreted independently by two experienced radiologists. Radiological patterns were analyzed and correlated with clinical presentations. Statistical analysis assessed associations between imaging findings and specific symptoms.
Results: Of the 165 patients, the mean age was 5.8 years, with a slight male predominance. Spasticity (74%), developmental delay or regression (65%), and seizures (42%) were the most common clinical presentations. MRI revealed bilateral symmetrical white matter abnormalities in 80% of cases. Metachromatic leukodystrophy showed frontal white matter involvement with U-fiber sparing; adrenoleukodystrophy demonstrated occipital changes with contrast enhancement; and Krabbe disease exhibited a tigroid pattern with thalamic and cerebellar involvement. Contrast enhancement was significantly associated with neuroregression (p = 0.01), while cerebellar atrophy correlated with seizures (p = 0.03).
Conclusion: MRI provides critical diagnostic value for leukodystrophies in pediatric populations, especially in resource-limited environments. Recognizing characteristic imaging patterns facilitates early diagnosis, aiding timely intervention and improving outcomes
Autonomic Dysreflexia: Gaps in Awareness and Clinical Preparedness Among Healthcare Providers
Full text linkBackground: Autonomic dysreflexia (AD) is a potentially life-threatening emergency affecting patients with spinal cord injuries at or above T6 level. Despite its severity, healthcare provider knowledge regarding recognition and management remains understudied, particularly in developing healthcare systems.
Objective: To assess awareness and clinical preparedness regarding autonomic dysreflexia among healthcare providers in tertiary care settings in Pakistan.
Materials and Methods: This cross-sectional study utilized a structured questionnaire administered to 127 healthcare professionals (35 consultants, 92 residents) across three tertiary care hospitals in Rawalpindi and Islamabad, Pakistan. The survey assessed knowledge of AD pathophysiology, recognition, and management approaches. Data were analyzed using SPSS version 25.0.
Results: The mean age of participants was 35.7 ± 7.4 years. Only 25.21% of respondents demonstrated adequate knowledge and preparedness for managing AD. Consultants showed significantly higher competency (48.15%) compared to residents (18.18%). Critical knowledge gaps were identified in first-line interventions, including proper patient positioning, identification and removal of noxious stimuli, and blood pressure management strategies.
Conclusion: This study reveals substantial gaps in awareness and clinical preparedness regarding autonomic dysreflexia among healthcare providers in Pakistan. The findings highlight an urgent need for targeted educational interventions, particularly for residents who often serve as first responders in emergencies
A Month in Cross Section: A Case Series of Eleven Sphenoid Wing Meningiomas: A Single Center Experience
Full text linkObjective: The objective of this work was to present our experience of SWM in a single-center case series of eleven patients in one month.
Materials & Methods: 11 cases of joint global sphenoid wing meningiomas were operated on in September 2022. Patient demographic, clinical, radiology, and perioperative salient features were noted. Post-operative clinical outcome included improvement in visual acuity, neural deficit, and headache. The extent of resection on radiology plus survival was noted as an outcome measure.
Results: Patients aged 28 to 65 years, with 9 females and 2 males, had giant sphenoid wing meningioma. Complete medial sphenoid wing involvement along with neurovascular structures, post operatively, they had visual deterioration; hence, the extent of resection was limited to prevent greater post-operative morbidity. 3/7 undergoing GTR had complete carotid artery encasement, in which full full-thickness MCA infarct was noted in 6 6-hour post-operative scan; they were later converted to a full 16 cm decompressive craniotomy. One survived with hemiparesis and aphasia while two died – male (49y), female (65), both had left craniectomies. STR was done in four patients, with cavernous sinus invasion and internal carotid encasement.
Conclusion: Giant sphenoid meningioma involving the medial sphenoid wing and associated neurovascular structures is surgically challenging and must be treated with STR. If GTR is to be attempted, early CT Brain postoperatively to prevent mortality
Outcomes of Syringosubarachnoid Shunting in Patients with Syringomyelia Following Foramen Magnum Decompression
Full text linkIntroduction: Syringomyelia following foramen magnum decompression can develop as a progressive neurological deficit that requires effective intervention. Syringosubarachnoid shunting has been brought to attention as a direct method to relieve syrinx pressure and relieve symptoms. The purpose of this study is to assess clinical and radiological outcomes of syringosubarachnoid shunting in such patients.
Material & Methods: A retrospective study was done of 21 patients of syringomyelia treated by syringosubarachnoid shunting at Hayatabad Medical Complex, Peshawar. The modified Japanese Orthopedic Association score (mJOA) was used to assess clinical recovery, and radiological outcomes included syrinx area change and span. Paired t tests and correlation analysis were performed using statistical analysis with p < 0.05.
Conclusion: Syringosubarachnoid shunting provides a safe and effective surgical option for the relief of syringomyelia after foramen magnum decompression with significant clinical and syringomyelia improvement and low complication rates. Nevertheless, it is still a good intervention when decompression alone is not enough
Evaluation of Seizure Disorders in Eclamptic and Pre-Eclamptic Patients: A Prospective Analysis from a Tertiary Care Hospital
Full text linkObjective: To evaluate the types, frequency, and clinical presentations of seizures in patients with eclampsia and preeclampsia, assess neuroimaging findings, including the prevalence of Posterior Reversible Encephalopathy Syndrome (PRES) and other cerebral abnormalities, and analyze maternal and fetal outcomes in relation to seizure characteristics and treatment strategies.
Materials & Methods: This prospective observational study was conducted at the Department of Obstetrics and Gynecology in collaboration with Neurology at Lady Reading Hospital, Peshawar, from January 2024 to June 2025. A total of 134 patients with eclampsia or severe preeclampsia presenting with seizures were enrolled. Clinical data, seizure type, imaging findings, treatment details, and maternal fetal outcomes were documented. The chi-square and logistic regression tests were applied for outcome associations’ assessments.
Results: Of the 134 patients 70.1 percent had eclampsia and 29.9 percent had preeclampsia with seizures Generalized tonic clonic seizures were observed in 88.8 percent focal seizures in 8.2 percent and status epilepticus in 3 percent Neuroimaging was performed in 63.4 percent of patients revealing PRES in 36.5 percent Magnesium sulfate was administered in 96.3 percent ICU admission was required in 24.6 percent and maternal mortality was 3.7 percent Intrauterine fetal demise occurred in 13.4 percent and NICU admission was needed in 16.4 percent of neonates.
Conclusion: Seizures in hypertensive pregnancies are predominantly generalized and associated with PRES Early clinical and imaging assessment with prompt magnesium sulfate administration is essential to improve maternal and fetal outcomes
Surgical Outcome of Limited Hemilaminectomy Performed for Spinal Stenosis
Full text linkObjective: To assess surgery-related outcomes of limited hemilaminectomy in patients with single-level spinal stenosis of the lumbar spine who did not respond to conservative therapy.
Materials & Methods: The retrospective observational study was done at KTH, Peshawar. 34 patients with a diagnosis of single-level lumbar spinal stenosis were treated surgically by limited hemilaminectomy. Assessments were done by clinical testing of walking capabilities, alleviation of radicular pain, and recovery of motor stiffness. The complications during postoperative were documented. The duration of follow-up was between 6 and 15 months (mean: 11.2 +/- 2.8 months).
Results: Good outcomes were achieved after surgery. The mean increase of walking distance was found in 82.3% of patients, whereas 70.5% percent could travel less than 100 meters before surgery (p=0.001). Radicular pain resolved within 88.2% of the patients at a span of six months (p=0.042). Of the 13 patients 38.2% who had dorsiflexion weakness, the recovery back to full normal was feasible within six months (p = 0.001). The postoperative complications were minor and transient, though it was present in only 8.8 percent of cases.
Conclusion: Limited hemilaminectomy is a potentially beneficial intervention that has a good clinical outcome regarding single-level lumbar spinal stenosis, with restricted functional capacity and a low complication rate. This method stabilizes the spine and eliminates the necessity to fuse or use instrumentation, thus representing a safe alternative to a common open laminectomy