Pakistan Journal Of Neurological Surgery
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Reconstruction of Large Meningomyelocele Defects with Local Fasciocutaneous Flaps
Get PDFObjective: To determine the versatility and safety of local fasciocutaneous flaps for reconstruction of large meni-ngomyelocele defects in terms of flap survival and dural coverage.Materials and Methods: Meningomyelocele is a congenital defect in the vertebral arches with cystic dilatation of meninges. Closure of the skin defect in broad based meningomylocele is a challenging reconstructive problem. We present our experience of use of local fasciocutaneous flaps for coverage of skin defects in meningomyelocele patients. In this descriptive case series we managed 15 patients with broad based myelomeningocele defects in the Plastic & Reconstructive Surgery department Lahore General Hospital, Lahore from March 2008 to April 2016. The age of patients ranged from 4 days to 8 years. The diameter of the defect ranged between 8×5 to 13×8 cm. In all patients, reconstruction of soft tissue defect was done with local fasciocutaneous flaps. We performed Double Z-plasty in 2 (13%) patients, bilateral transposition flap in 4 (26%) patients, bipedicle skin flap in 4 (26%) pati-ents, unilateral long superiorly based flap in 3 (20%) patients, and inferiorly based flap based on gluteal perfo-rator in 2 (13%) patients. Donor site was primarily closed in 10 (66%) patients.Results: In 5 (33%) patients flap donor area was skin grafted. Superficial wound dehiscence was seen in 2 (13%) patients. One patient (6%) had necrosis of distal part of flap which was managed conservatively. No neuro-surgical complication occurred post operatively. Average follow up of 2 years showed no recurrence or dural sac herniation in any patient.Conclusion: Reconstruction of large meningomyelocele defects with local fasciocutaneous flaps provides safe and predictable outcomes and is the method of choice for most of the defects in the lumbosacral area
Risks of Surgery for Myelomeningocele in Children
Get PDFObjective: To know about complications in Myelomeningocele (MMC) surgery.Material and Methods: Fifty five children underwent surgical repair of MMCs and represent our experience about complication in surgery for MMC. Retrospective observational study carried out in Neurosurgery ward, Lady reading hospital Peshawar, from 2013 to 2015. Patients suffering from MMC were admitted. The clinical, radiological and laboratory finding of patients were documented on a designed proforma. Moreover ventri-culoperitonial shunting (V/P) was performed for children who had or developed hydrocephalus. Eliptical incision in vertical plane was given in 45 cases and horizontal incision in 6 cases. Plastic surgery unit consulted for very large MMC in rest of 4 cases and transposition of gluteus maximus musculocutaneous unit performed. All patients with MMC of both gender and age range from 1 month to 10 years who were willing and fit for surgery were included in this study and all those who were not willing and fit for surgery were excluded. The study was approved by Institute of Research in Ethics and Biomedicine (IREB).This study will help to make recommen-dations.Results: Patients in this study were in the age range of 1 month to 10 years. Mean age was 1.8 years. Thirty seven patients (67%) were Paraparetic (MRC grade from 1 to 4) and 18 patients (32.72%) were completely paraplegic. Seventeen patients (30.9%) had ruptured MMC at presentation and underwent surgery in emergency. Fifteen patients (27.27%) had V/P shunting before surgery for MMC and 11 patients (20%) developed hydro-cephalus after excision and repair of MMC and V/P shunting carried out. Seven patients (12.72%) developed wound dehiscence and CSF leak and subjected to redo surgery. Three patients (5.45%) had wound infection followed by meningitis and two patients (3.63%) died after surgery.Conclusion: From this study we concluded that wound dehiscence and CSF leak are the most common complication after surgery for MMC and can be prevented by tensionless closure of the wound. In MMC patients with overt hydrocephalus prior to repair and excision of MMC V/P shunting should be performed. If patient develop hydrocephalus after surgery then immediate diversion of CSF should be carried out
Management of Postoperative Pseudomeningocele following Posterior Cranial Fossa Surgery
Get PDFObjective: Pseudomeningoceles are common complications after posterior fossa surgery. Management guide-lines are lacking, and radically different suggested treatments varying from observation to immediate surgical intervention are encountered in literature. The purpose of our study was to detail our experience in the manage-ment of pseudomeningocele following posterior fossa surgery.Methods: A retrospective, single-center study was conducted on 137 patients who underwent elective posterior fossa surgery for a variety of diseases. Patients with post operative pseudomeningocele formation were initially treated with conservative measures including bed rest, head elevation, pressure dressing and CSF lumbar drain-age. Surgical re-exploration and repair of the dural rent was done in case the pseudomeningocele didn’t settle with these conservative measures. In patients having gross hydrocephalus on post-operative CT scan a VP (ventriculo-peritoneal) shunt was done in case the conservative measures failed.Results: There were 8 (5.8%) cases of pseudomeningocele formation after posterior fossa surgery. The pseudomeningocele didn’t settle with conservative measures in any case. Surgical re-exploration and repair of the dural rent lead to the settlement of pseudomeingocele in four cases. VP shunting for gross hydrocephalus on post operative CT lead to the settlement of the pseudomeningocele in the other four cases. Conclusion: Although it has been stated in literature that most cases of pseudomeningocele settle with conser-vative treatment with only a few requiring surgical intervention, our findings were different with conservative measures failing to resolve the pseudomeningocele in all the cases. We believe that it would be beneficial to take an aggressive attitude toward this condition and to consider the possibility of early surgical intervention more seriously
Anterior Decompression and Fixation with a Reconstruction Plate in Cervical and Cervicodorsal Spinal Tuberculosis: A Study of 39 Cases
Get PDFObjective: To evaluate the efficacy of anterior instrumentation in patients with subaxial and cervicodorsal spinal tuberculosis in reconstruction of the spine, providing pain relief, neurological recovery and prevention of deformity.Patients and Methods: This is a hospital based reteospective study conducted at Departments of Neurosurgery, Lahore General Hospital and Jinnah Hospital Lahore. Medical records of all the patients operated for subaxial cervical and cervicodorsal (C3-D2) spinal tuberculosis treated by anterior approach during January 2004 to December 2009 were reviewed and analysed. A five drug antituberculous regimen were used for 15-18 months. The follow up ranged from 2 years to 4 years. Clinical and radiological assessment was carried out at intervals.Results: Between January 2004 and December 2009, 39 patients of subaxial cervical and cervico-dorsal (D1, 2) Spinal tuberculosis has been operated by anterior approach. Three patients with involvement of D 1 and D2 vertebrae had a similar approach without excision of medial end of clavicle or manubrium sterni. The age ranged from 18-55 years with a mean age of 32.5 years. There were 26 male and 13 female patients with a male to female ratio of 2:1. Patients presented with Fever and weight loss 10 patients (25.6%), Pain 36, (92.3%), Dysphagia, 3 (7.6%), Motor deficit, 36 (92.3%), Small muscle wasting in hand, 6, (15.3%), Sensory deficit, 32 (82%), Sphincter involvement, 16 (41%), Cervical deformity, 30 (76.9%), Spasticity, 32 (82%). The mean duration between onset of symptoms and clinical presentation in our series was 9.3 months (range3 to 20 month). Cervical x-rays were carried out immediately post op and then at 3, 6, 12, and 24 months. Pain improved in 32 patients (88.8%). Motor deficit improved in all 36 patients. Degree of improvement was less in patients with severe motor deficit preoperatively. Spasticity improved in 28 patients out of 32 (87.5%).Sensory Deficit slowly improved in all 32 cases. Sphincter involvement improved in all 16 cases. Spinal deformity improved in 26 patients out of 30 (86.6). Small muscle wasting of hands present in 6 patients preoperatively didn’t recover in 2 patients. The results were classified as excellent (Grade 5/5 power on last follow up, no pain or deformity, 28 patients 71.7%), good (motor power Grade 4/5, mild pain, residual wasting but no functional sequale, 8 patients, 20.5%) and fair (persistent disability in 4 patients 7.7%). A satisfactory relief of pain and neurological improve-ment was seen in 36 patients (92.3%).Conclusions: Anterior reconstruction using titanium reconstruction plates and iliac bone graft for stabilization of the subaxial and cervicodorsal region tuberculosis is a very useful adjunct in improving neurological deficit, relieving pain and preventing kyphotic deformity. A satisfactory segmental stability and fusion is achieved by this techniqu
Frequency of Neurosurgical Lesions in Patients with Minor Traumatic Head Injuries
Get PDFObjective: To observe the characteristics of minor head injuries (HI) receiving treatment at our Neurosurgery Department and their evolution in the short term.Materials and Methods: Study included patients over the age of 14 who had sustained a minor HI, had a cranial CT scan and had been admitted for observation in the neurosurgery ward. Descriptive and retrospective analysis.Results: A total of 114 patients were included in the study. 76% presented with Glasgow 15 and 78% were male. Brief loss of consciousness (70%) and amnesia (52%) were the two most frequent alertness clinical findings. Surgical lesions were (15%) depressed skull fractures, 8% had extradural hematomas, cerebral contusions in 5.2% and subdural hematomas in 1%.Conclusions: As patients with minor traumatic brain injury have significant number of surgical lesion so Clinical guidelines must be set up for the treatment of patients with minor traumatic brain injury
The Frequency of Otogenic Intracranial Complications in Chronic Suppurative Otitis Media with Cholesteatoma
Get PDFObjectives:1. To determine the frequency of otogenic intracranial complications in chronic suppurative otitis media with cholesteatoma.2. To discuss the diagnosis and management of patients presenting with otogenic intracranial complications.Study Design: It was a prospective, descriptive and cross – sectional study using convenience sampling technique.Materials and Methods: This was a combined study conducted in the ENT Department of Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar and the ENT Department of Mardan Medical Complex, Mardan over a period of 3 years from January 1, 2007 to December 31, 2009. Cases presenting with chronic suppurative otitis media with cholesteatoma were studied and the frequency of otogenic intracranial complications occurring in these cases was calculated.Results: A total of 85 cases were studied. The ages of the patients ranged from 8 to 40 years. All the patients had chronic suppurative otitis media with cholesteatoma. The commonest complaint in cases with suspected intra-cranial complications was deep seated earache followed by persistent headache. Meningitis and extradural abscesses were the commonest intracranial complications. The frequency of intracranial complications in our study was found to be 11.76%.Conclusion: Otogenic intracranial complications due to cholesteatoma continue to pose a significant risk to the patients. High index of suspicion is essential for diagnosis and skilful management of otogenic intracranial comp-lications. Early recognition is possible and these cases should be managed in close collaboration with a neuro-surgeon
Role of Ventriculoperitoneal Shunt for Haemorrhagic or Ischemic Strokes Causing Hydrocephalus
Get PDFPosterior fossa hemorrhagic involve or infract associated hydrocephalus are serious neurosurgical emergencies which requires immediate and prompt action.Purpose: To highlight the role of VP shunt in the management plan of Hydrocephalus caused by spontaneous hemorrhagic or ischemic infarcts.Material and Methods: This is retrospective study of 16 cases over a period of 4 years from March 2007 to March 2011 conducted simultaneously at Neurosurgical departments of CMH Lahore, CMH Multan and Farooq Hospital Lahore.Results: A total of 16 cases were included in this study and all those patients underwent some sort of CSF diversion procedure for obstructive hydrocephalus. Ten Patients (62.5%) were male and six (37.5%) patients were female. The age ranged from 32 – 70 years with mean age of 53.4 years. Clinically all patients presented with headache, vomiting and neck pain followed by loss of consciousness. Glasgow coma scale ranged from 5/15 to 12/15. The radiological findings were those of hemorrhagic or ischemic infarcts causing obstructive hydro-cephalus. Patients were broadly divided into two main groups with eight patients in each group. Group A inclu-ded 6 males and 2 females, all these patients were managed conservatively for the hemorrhagic or ischemic strokes while they underwent VP Shunt for the obstructive hydrocephalus. Two of these patients (a male and a female) had thalamic bleed (hemorrhagic stroke) with third ventricular blockade. These two patients were also managed by VP Shunt only. Outcome of patients in group A was excellent in 7 patients whereas one patients developed complications with prolonged hospital stay but ultimately recovered and discharged. Group B inclu-ded 8 patients (4 male and 4 female) who underwent hematoma evacuation of cerebellar bleed along with place-ment of external ventricular drain (EVD). EVD was converted to VP Shunt in six patients when they deteriorated after blocking EVD on 5th post operative day. 2 patients out of these eight did not deteriorate on EVD blockade and VP Shunt was not passed in these patients and they had excellent recovery. One patient died in group B. One patient required redo surgery due to Shunt Blockade and had poor recovery whereas two more patients had poor recovery due to other reasons including poor neurological status pre operatively. Two patients had fairly good recovery after converting EVD into VP Shunt.Conclusion: Obstructive hydrocephalus caused by hemorrhagic stroke or infarcts is a relatively rare entity requiring some sort of CSF diversion. Patients who are having smaller hematomas with hydrocephalus and GCS more than 8/15 can be managed with VP Shunt alone
Peripheral Nerve Injuries Presenting to a Tertiary Care Hospital an Experience with 40 Patients
Get PDFObjective: To study the different aspects of peripheral nerve injury presenting to a tertiary care hospital.Material and Methods: This descriptive study was conducted in Neurosurgery Department of PGMI, Lady Reading Hospital Peshawar from June 2009 to June 2011. A total number of 40 patients were studied through randomized sampling technique. The study included patients of all age groups and both gender. All patients who presented at the time of injury and up to duration of 9 months since time of injury were included in the study. Patients with injection injury and traction injury were excluded. All the data was collected by using a Proforma. Data was analyzed by descriptive statistics using SPSS software version 17.Results: Majority of the patients were male, 36 (90%) and 4 (10%) were female. Gunshot injury was the commonest cause 23 (57.5%). The commonest affected age group was 20 – 30 years (37.5%). Children below 10 years and people above 60 years of age were least affected. Peripheral nerve injuries due to Bomb blasts were 4 (10%) followed by Glass injuries. Iatrogenic nerve injury in orthopaedic and general surgical procedures was in 3(7.5%) patients. Injuries with sharp weapons such as knife and stabs were seen in 4 (10%) patients. Two patients were having concomitant vascular injury. Patients with sharp injuries had excellent results while patients in whome the cause was fire arm injury the results were not much promising. All the patients were followed up for maximum period of more than 1.5 years.Conclusion: Majority of our patients were male. Major etiological factor was firearm and bomb blast injuries in our study. Furthermore, patients with sharp injuries had excellent results
Transnasal Trasnssphenoidal Surgery for Pituitary Tumours
Get PDFObjective: To determine the frequency of early post-operatively complications of transnasal transsphenoidal surgery for pituitary adenoma.Study design: Descriptive study.Place and Duration of Study: Pak International Medical Science Khyber Pakhtoonkhawa from 1st February 2008 to 31st July 2011.Material and methods: A total 41 patients with pituitary adenoma fulfilling the inclusion and exclusion criteria were included in this study. All patients were undergone transnasal transsphenoidal surgery. These patients were followed up for early complications of transsphenoidal surgery for one month.Results: Out of 41 patients, there were 23 (56.09%) males and 18 (43.9%) females. The age of patients ranged from 10 to 70 years. In this study the overall mean age was 44.75 years. Majority of patients fourteen (34.14%) were in the age range of 41 – 50 years, followed by eleven (26.8%) patients in age group of 31 – 40 years, seven (17.07%) patients were in the age range of 51 – 60 years, five (12.1%) in the age range of 61 – 70 years, three (7.31%) in the age group of 21 – 30 years and one (2.4%) in the age group of 10 – 20 years. Early post-operative complications were diabetes insipidus in four (7.31%) patients, CSF leak two (4.87%) patients, meningitis in one (2.43%) patient and epistaxis in one (2.43%) patient.Conclusions: Surgical complications of Transnasal transsphenoidal surgery are minimal. Transnasal trans-sphenoidal surgery is a safe and effective treatment for pituitary tumour
Microvascular Decompression for Trigeminal Neuralgia
Get PDFBackground: The majority of patients with trigeminal neuralgia can be managed by medical treatment. Those patients who are not relieved with medicines can be offered some surgical treatment. Microvascular decompress-ion (MVD) of the trigeminal nerve in the root entry zone is the most suitable surgical procedure.Methods: This study included 80 patients who underwent MVD for trigeminal neuralgia from January 2002 to December 2005.Results: Out of the total 80 patients, 48 (60%) were males and 32 (40%) were females with male: female ratio of 3:2. The maximum number of patients was in the 6th decade of life (30%) followed by 7th and 5th decades (over 18%). Peroperatively, an arterial loop was found compressing the 5th nerve in the root entry zone in 60 (75%) patients, only veins in 10 (12.5%) and an artery and a vein (combined) in 6 (7.5%) patients.Conclusion: An arterial loop compressing the trigeminal nerve at root entry zone is the commonest finding at microvascular decompression (75%), followed by veins (12.5%).Keywords: Trigeminal neuralgia, Microvascular decompression, Root entry zon