Pakistan Journal Of Neurological Surgery
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The Role of Radiology (X-Ray versus Computed Tomography) in Medicolegal Cases Presented at a Tertiary Care Hospital in Pakistan
Get PDFObjectives: A prospective observational study was aimed to assess the role of plain radiographs and computed tomography in detecting head injuries presented at the medicolegal office at the Forensics and Radiology Departments, Gambat Medical Hospital, Sindh.
Material and Methods: All cases referred from the Medicolegal Office (MLO) with head injury were included. All victims underwent X-ray head and computed tomography skull was done with 1 or 1.5 cm thick axial sections without administration of intravenous contrast. The radiological reports of X-ray head and CT scans were documented and comparatively evaluated.
Results: Mean age was 38.63 ± 3.91 years. In 51 (45.13%) cases, X-ray was able to detect skull fracture, while CT scan detected 64(56.64%) skull fractures. There were 54 (84.3%) true positives, 3 (2.6%) false positives, 10(8.8%) false negatives, and 40 (40.7%) true negatives. The accuracy of X-ray to detect skull fracture was 88.50%.
Conclusion: X-ray had a sensitivity and specificity of 84.38% and 93.88%, respectively. It is a reliable tool to detect skull fractures in victims of assault in comparison with CT scans. X-ray is also associated with low dose radiation exposure as compared with CT scan which delivers 70 times more exposure than the former
Total and Near Total Composite Lower Eyelid Defect Reconstruction with Glabella Flap: An Excellent Option with Limited Donor Site Availability
Get PDFBackground/Objective: Traumatic loss of the lower eye lid is usually combined with the paucity of adjacent flaps to reconstruct composite defects. We describe the use of Glabellar flaps with composite or cartilage graft to reconstruct total or near total composite lower eyelid defects and its outcome.
Material and Methods: This case series was done from January 2017 to December 2019. Patients of either gender, with unilateral post traumatic partial or full thickness lower eyelid defect of 75% eyelid loss or more and Glabellar flap as only remaining option to reconstruct the anterior lamella were included. Patients with medial, lateral canthi, upper eyelid and injuries to orbital contents were excluded. The outcome was assessed on follow-up by the presence of epiphora, ectropion, lagophthalmos, obstruction of vision, graft infection/ extrusion, lower lid retraction, donor site scarring and the need for flap debulking.
Results: 12 patients were operated for lower eyelid defects. 2 (16.7%) patients had total loss of eyelid, while 10 (83.3%) had near total loss, 7 (58.3%) patients presented with partial thickness loss of the eyelid, while rest presented with full thickness loss. 1 patient (8.3%) presented with epiphora, similarly 1 (8.3%) had obstruction of vision in down gaze and 1 (8.3%) had conjunctivitis. None had any other complaint.
Conclusion: Glabellar flap together with composite or cartilage graft is an excellent option to reconstruct total or near total composite lower eyelid defects
COMPARISON OF OUTCOMES OF ENDOSCOPIC MICRODISCECTOMY VERSUS CONVENTIONAL DISCECTOMY FOR LUMBER DISC DISEASES
Get PDFIntroduction: Chronic lumbosacral pain is a communal and difficult clinical condition at the center of pain management. The most common surgical indication is back pain or intractable and severe functional impairment that does not respond to conservative measures. In this study we have compared the results of endoscopic d microdiscectomy and conventional discectomy procedure.
Material and Methods: We included 54 patients with severe lower back pain who did not improve after long-term conservative treatment and who had level 3 disc prolapse, radiating to one or both lower limbs. Oswestry Disability Index (For Low Back Pain) was documented with questionnaire comeback and applied as a clinical tool for valuation.
Results: The average age of the 54 patients was 46 years and 75% of patients have paracentral disc protrusion. The mean endoscopic microdiscectomy surgery time was 110 minutes; was longer than conventional discectomy (82 minutes). However, blood loss was very small compared to conventional discectomy. According to the ODI result, both conventional and endoscopic discectomy gave same outcomes in all classes.
Conclusion: Endoscopic microdiscectomy is a new, effective and safe procedure that reduces the invasiveness of the surgical approach. The results obtained by this approach are comparable with those obtained with open discectomy to alleviate symptoms during prolonged observation, and because the tissue has minimal trauma, it is much better in early mobilization and morbidity
Endoscopic Third Ventriculostomy: A Comparable Alternative to Ventriculoperitoneal Shunt for Obstructive Hydrocephalus Secondary to Infratentorial Tumors
Get PDFObjective: To establish ETV as a comparable alternative to ventriculoperitoneal shunt for obstructive hydrocephalus secondary to infratentorial tumors.
Methods: 40 Patients with infratentorial tumors presenting with hydrocephalus were enrolled in a prospective descriptive case series. Symptoms, neurological examinations, CT scan and intra-operative findings were used detect the complications at 03 months.
Results: Mean age = 31.98 ± 15.24 years, female to male ratio of 1:1.2. The KPS score of the participants was ? 70% and ETVSS ?80. Average operative mean time was 21 ± 2.82 minutes. Within first week, the improvement in symptoms was recorded (CI=95%): headache – 87.5% (p < 0.001), nausea vomiting - 84% (p < 0.001), gait disturbance – 59.3% (p=0.442) seizures improvement -100% (p=0.016) and urinary incontinence – 66.7% (p=0.687). Radiological improvement in hydrocephalus on CT scan was seen in one patient within 24 hours – 2.5% (p= <0.001), 12.5% (p<0.001) after two weeks and 87.5% (p= <0.001) after three months post-operatively (CI 95%). Most common of these were decrease in the size of third ventricle and decrease in the size of frontal horns of lateral ventricles. However, complete resolution of radiologic features was observed in two patients only 5% (p<0.001). However, complete resolution of radiologic features was not observed in any patient. No intra-operative or post-operative complication of ETV was recorded.
Conclusion: ETV is a quick and safe method for CSF diversion in obstructive hydrocephalus alleviating the need for placement of VP shunt hardware, thus eliminating foreign body related cranio-abdominal complications
Post-Traumatic Syringomyelia: A Case Series
Get PDFIt is relatively common to occur in a Tertiary Care Neurosurgical setup to get a case of Syringomyelia proximal or distal to a space-occupying lesion (SOL) or site of spinal cord compression. In this case series, we are presenting two cases in which syringomyelia developed after traumatic spinal cord injury. On initial radiological investigations, the first case presented as an old D12 fracture with Post-traumatic syrinx formation but on complete workup for the extent of the syrinx, another lesion was found incidentally in the form of an intradural extramedullary SOL at the level of cervicomedullary junction. The SOL turned out histologically as WHO Grade I Meningioma. The second case presented as syrinx formation after gunshot (fire-arm) penetrating spinal cord injury to the D11-12 vertebrae. Treatment plans of both these patients are presented here in detail along with the literature review
Improvement of Headache in Patients after Occipital Extradural Hematoma (EDH) with Less Than 15 ml of Volume after Single Burr Hole Evacuation and Placement of Drain
Get PDFObjective: We hypothesized that if we operate occipital extradural hematoma (EDH) having a volume less than 15 ml by single burr hole evacuation of extradural hematoma (EDH) and placement of drain without doing craniotomy then clinical status of the patients particularly headache improves.
Method: An observational study of 15 patients (with presenting GCS: 8–13) was conducted on patients who were operated in Punjab Institute of Neurosciences (PINS). All patients had acute extradural hematoma less than 15 ml after a road traffic accident (RTA). The age range was 22 – 45 years. All patients were operated on within 12 hours of road traffic accident. The timing of surgery was in the range of 1-2 hours.
Results: In all patients, surgery was performed by a single burr hole at the occipital region at the site of occipital EDH and the drain was placed in an extradural position. Co-morbidities in our patients were DM, polytrauma. Receiving GCS was 9 in 2 (13.33%) patients, was 13 in 10 (66.67%), was 8 in 1 (6.66%) patient and receiving GCS was 15 in 2 (13.33%) patients. All patients were assessed clinically on 5th post-operative day. It was seen headache was relieved on 5th post-operative day in all patients except 1 (6.66%) patient. Our 1 (6.66%) patients came for follow-up with the complaint of headache and vomiting which was managed conservatively.
Conclusion: Surgery by single burr hole evacuation and placement of drain is a safe method if occipital EDH is less than 15 ml in volum
Outcome Comparison of Endoscopic Third Ventriculostomy versus Ventriculoperitoneal Shunt in Obstructive Hydrocephalus
Get PDFBackground and Objectives: To assess the outcome of Endoscopic Third Ventriculostomy (ETV) versus Ventriculoperitoneal Shunt (VPS) in Obstructive Hydrocephalus in terms of infections, foreign bodies, cost-effectiveness, and length of hospital stay.
Materials and Methods: It was a Randomized Controlled Trial study, in which 30 patients with Obstructive Hydrocephalus were divided into two groups one was treated with (ETV) and the other was treated with VP Shunt and the patients were followed up for 1 year.
Results: Patients were divided into 2 groups, 15 were treated with ETV, and 15 were treated with VP Shunt. Length of stay for VP shunt was 7 ± 0.85 days and for ETV mean stay was 2.93 ± 1.1 days. The complication was observed in 4 (26.7%) treated with VP Shunt and in 3 (20%) patients with Endoscopic Third Ventriculostomy. In ETV, 3 (20%) patients had recurrence whereas in VP shunt in 1 (6.67%) had an infection and in 3 (20%) patients had recurrence (upper-end blockage) and the overall success rate was 76% in both the procedures and in VP Shunt 73.3% and ETV 80%. Overall there were no complications found in 23 (76.6%) patients, in 3 (10%) patient’s complications were found at 1st month, in 3 (10%) complications were observed at 3rd month, and in 1(3.3%) complication was recorded at 6th month.
Conclusion: ETV was found better in terms of length of hospital stay, cost-effectiveness as well as minimal complication rate as compared to VP shunt
Surgical Outcome of Brain Abscess after Single Burrhole Aspiration Technique in Terms of Glasgow Outcome Scale
Get PDFObjectives: This case-series was aimed to determine the surgical outcome of brain abscess after a single burr hole aspiration technique in terms of the Glasgow outcome scale (GOS).
Material & Methods: 100 cases were taken in the study with brain abscess. The favourable outcome included those patients with postoperative GOS of 4 or 5, at discharge and one month postoperatively whereas unfavourable outcome included patients with postoperative GOS of less than 4, at discharge and one month postoperatively.
Results: Of the 100 patients included, there were 72 (72%) males and 28 (28%) females. The overall mean diameter of the abscess was 6.01 cm ± 1.90. Mean GOS was 2.95 ± 0.86 while mean GOS 3.79 ± 1.18. In this study 75% (n=75) patients presented with a GCS of 12 or less. Among these patients, 2 patients presented with a GCS of 5, 6 patients with a GCS of 7, 9 with GCS 8, 11 with GCS 9, 18 with GCS 10, 15 with GCS 11 and 14 patients presented with a GCS of 12. A favourable outcome was observed in 73 (73%) patients (GOS = 4 and 5), while 27 (27%) were in the unfavourable outcome group.
Conclusion: Although most of the patients present with a good neurological state, those who present with lower GCS are particularly prone to the poor postoperative outcome and higher mortality. The size of the brain abscess is also an important predictor of the postoperative outcome. The overall outcome for brain abscess aspiration was good
Complications Following Comparison of Surgery for Chronic Subdural Hematoma, With and Without Postoperative Drainage Tube
Get PDFObjectives: Chronic subdural hematoma (CSDH) is one of the most common entities treated in neurosurgery. Postoperative subdural drainage employed after burr hole evacuation for treating CSDH reduces recurrence, but whether it leads to increased surgical complications compared to no postoperative drainage is debatable. The present study was designed to assess whether postoperative subdural drainage leads to increased surgical complications following burr hole evacuation of CSDH compared to no drainage.
Materials and Methods: The medical records of 69 patients treated with burr hole evacuation for chronic subdural hematoma between July 2013 to April 2014 were retrospectively analyzed. The patients were divided into two groups. In group A patients, postoperative subdural drainage had been employed following burr hole evacuation of CSDH, while in group B patients there was no drainage. The two groups were then compared for the development of surgical complications other than recurrence.
Results: Sixteen patients developed complications. Acute Subdural hematoma formed in 3 patients. There was intraparenchymal drain insertion in 6 patients. An empyema developed in 2 patients, while one patient each developed an Extradural hematoma, fits, contusion, and hemorrhagic infarction. All the complications occurred in the group A patients receiving postoperative subdural drainage. Postoperative subdural drainage tube was found to be significantly associated (p = 0.0017) with complications.
Conclusion: We conclude that postoperative subdural drainage following burr hole evacuation of chronic subdural hematoma is associated with increased surgical complications compared to no drainage
Management and Outcome of Ruptured Anterior Circulation Cerebral Aneurysms – An Experience of Neurosurgery Department of Nawabshah
Get PDFObjectives: To analyze the management and outcome of ruptured anterior cerebral circulation aneurysm by a variety of procedures including microsurgical clipping.
Material and Methods: A quasi-experimental study, carried out in The Department of Neurosurgery, Peoples’ Medical University Hospital Nawabshah from November 2010 to December 2020.We enrolled 38 patients and 40 aneurysms who presented with ruptured aneurysms. Hunt and Hess grading was used to evaluate the neurological status and ruptured aneurysms were managed by microsurgical clipping, excision, and suture ligation.
Results: Out of 38 patients Male were (23) 61% and females were (15) 39%, with a mean age of 50±25 years with aneurysmal subarachnoid hemorrhage and graded according to Hunt and Hess grade and fissure grading. Middle cerebral artery aneurysm was 45%, Anterior communicating artery 30%, Anterior Cerebral Artery 10%, carotid bifurcation 2.5%. Multiple aneurysms at internal carotid plus anterior communicating artery (n = 2) and internal carotid plus middle cerebral artery aneurysms n = 2. Distal anterior cerebral (n = 1). In 33 patients, the aneurysm was clipped, in 3 patients with fissure grading 4 and huge intracerebral bleed with signs of brain herniation, decompression plus aneurysm clipping was done, suture ligation (n = 1) and excision of a giant aneurysm (n = 3).
Conclusions: Microsurgical clipping is considered an ideal modality to secure a ruptured intracerebral aneurysm. Rarely it can be amendable by suture ligation, or excision. Presenting Hunt and Hess, fissure grading, age, and volume of intracerebral bleed have a direct impact on prognosis