Pakistan Journal Of Neurological Surgery
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Craniovertebral Junction Lesions and Single Stage Anterior Decompression Followed by Posterior Fusion
Get PDFObjective: To asses the outcome of transoral microsurgical excision of anterior placed craniovertebral junction (CVJ) lesions excision followed by posterior craniocervical stabilization. Study Design: Qausi Experimental study. Setting: Department of neurosurgery PINS/Lahore General Hospital, Lahore. from May 2017 to Aug 2018. Inclusion Criteria: Male and Female patients of 12-65 yrs of age with compressive lesion at the ventral aspect of craniovertabral junction. Exclusion Criteria: Lateral and posterolateral lesions, lesion below C2 vertebral body, patient unfit for anaesthesia and surgery. Material and Methods: 12 consecutive patients coming in OPD and emergency department of our unit and fulfilling the inclusion criteria were studied. All patients were prepared for the surgery and written informed consent taken from all our patients. The patients underwent anterior trans oral microsurgical excision of the tumour followed by posterior fixation. Results: Out of 12 patients (range 12–65 years); Rheumatoid arthritis in 1 patient, tumor in 5 patients or trauma in 4 case and basilar invaginations in 2 patients. All my patients had headache (cranial and/or high-cervical pain), 73% of patients presented with quadriparesis, and 29% presented with basal cranial nerves involvements. Anterior decompression followed by posterior craniocervical fixations was done in all patients in same sitting. Out of 5 patients having severe neurological deficits preoperatively 3 improved. The remaining 7 patients have mild to moderate neurological deficits improved gradually throughout the follow-up periods to independent level. Among complications mortality in 1 patient and morbidity in the form of dural tear, CSF leak and infection in 2 patient). Craniocervical instability was seen in one patients after 3 months of surgery. Conclusion: A good surgery with proper decompression at the craniovertebral junction is technically difficult procedure and demands expertise. It needs proper preoperative planning and investigations and adequate decompression and stabilization with proper implants
Use of Endoscopic Third Ventriculostomy (ETV) Success Score to Predict the Outcome of Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus
Get PDFObject: In February 2011 Abhaya V. Kulkarni et al. reported endoscopic third ventriculostomy success score in order to predict the outcome of obstructive hydrocephalus. After ETV the object of the present study was to evaluate this predictive value in our own setup, prospectively.Materials and Methods: From April 2011-November 2012, 110 endoscopic third ventriculostomy procedures were performed for obstructive hydrocephalus of different etiologies at the department of pediatric neurosurgery, the Children’s Hospital Lahore. All of these cases were more than 6 months old and the data was analyzed by the senior author.Results: A total number of 110 patients were operated between April 2011 – November 2012. The patients’ ages ranged from 6 months – 13 years. No child below 6 months was included in this study. Children were stratified into 4 age groups: 6 months – 1 year (Group – 1), 1 year – 2 years (Group – 2), 2 years – 10 years (Group – 3) and more than 10 years (Group – 4). The score was calculated for each patient before surgery according to ETVSS and at the end of 6months the success or failure of the ETV was determined by clinical, radiological measures. Out of 110 patients, only 80 were available at the completion of 6months period after surgery. The ETV was successful in 56 patients (70%). Patients below 1 year achieved lowest success. Of the ten patients with a high probability of ETV success, eight (80%) were successfully treated.Conclusion: The results show that EVT success can be predicted very well by ETVSS and it should help in establishing surgical selection criteria in order to obtain high success rate. It can also help in preparing the patients and their families to the expected outcome
Midline Depressed Fractures of the Skull
Get PDFObjective: To evaluate the results of management of middle depressed fracture skull.Depressed skull fracture is a common neuro-traumatic emergency. The commonest causes in our society are fall from height and road traffic accident. The frequency of depressed fractures is that it occurs in 75% in fronto-parietal region, 10%1 in temporal region, while in occipital is 5% and in others is 10%. In time surgical manage-ment gives excellent results and leads to minimize the sequel of this condition. Most of the causes can be pre-vented just by adopting preventive measures. The condition can be treated in periphery hospital as well, if trained personals are available. Midline depress fracture are rare. Depressed fracture over venous sinuses requires special handling. Surgical elevation involves massive blood loss. Most of them are treated conservatively.Material and Methods: We conducted a 4 years study in the department of Neurosurgery, Lahore General Hospital from 2009 to 2013.Results: We included 30 patients of mid line depressed fractures in which 20 were treated by surgical elevation and 10 by conservative management. Follow of 3 months to 1 year. In a total of 3750 patients who presented in the emergency department, 540 (14.4%) patients were operated for depressed skull fractures in which midline depressed fractures were 20 (4%). There were 20 patients in whom the anterior 1/3rd of superior sagittal sinus was involved, in 6 patients the middle 1/3rd of superior sagittal sinus was involved while in only 4 patients the posterior 1/3rd of superior sagittal sinus was involved. We paid special attention to these midline fractures involv-ing the venous sinuses. In 4 of our patient we encountered severe blood loss as the depressed fragment was being plugged in sinus tear. In 12 patients we carefully elevated the depressed fractures and gained control over the venous sinus as soon as possible with the help of spongiston and packing technique. In 8 patients the fracture site was not contaminated with foreign material, there was no cosmetic issue and no focal deficit found, they were managed by scalp debridement along thorough irrigation and primary closure. Out of operated 20 patients only two patients presented with mild wound infection but it settled down with proper antibiotic therapy. In the con-servative group out of 10 patients 2 patients developed epileptic seizure after 3 months and 7 months of trauma and they were managed by giving antiepileptic drugs.Conclusion: In our study we concluded that elevation of depressed fracture over SSS can be attempted whenever patients clinical condition warrant. Elevation of the bone along with debridement of the wound resulted in rapid and dramatic resolution of signs and symptoms of raised ICP and venous hypertension. The study also showed an improvement in the cosmesis and reduction in the overall wound infection rate
Desarda Vs Lichtenstein “Hernioplasty” A One Year Comparative Study at a Teaching Hospital Lahore
Get PDFAcomparative, prospective study was carried out in surgical department of LGH to evaluate the efficacy of Dessardahernioplsty technique by comparing with Lichtenstein repair in terms of post operative pain, hospital stay, rate of early and late complications and recurrence. Total (n=60) cases were divided in two groups A and B. with mean age 41.5 and 43.5 years for dessarda and Lichtenstein groups respectively. Insignificant statistical difference was noted in both groups as for as severity of acute pain, post operative hospital stay and wound infections are concerned. Regarding chronic pain and recurrence rate, patients in group A (Dessarda) show statistically significant advantage over group B (Lichtenstein). It, therefore was concluded that Dessarda-hernioplasty technique is useful in our patients as no foreign material has to be inserted that makes it cost effective with advantage of less chronic pain and zero recurrence rate at the end of one year
Surgical Outcome of Chronic Subdural Hematoma by Two Burr Hole Technique
Get PDFObjective: To study postoperative outcome of chronic subdural hematoma by two burrhole technique.Study Design: It was a descriptive cross sectional study.Place and Duration of Study: It was a hospital based study which was conducted in the Department of Neurosurgery HMC, from 10th June 2013 to 10th June, 2015.Materials and Methods: This study was conducted on 193 patients of chronic subdural hematoma. These patients were selected on the basis of history, clinical features and CT scan brain showing presence of chronic subdural hematoma. For data analysis SPSS version 20 software was used.Results: We studied one 193 patients. Among these patients 145 were male and 48 were female with a male to female ratio of 3.1:1. The age range was 20 to 80 years with an average of 65.9 years. One hundred and ten patients (59.0%) gave a history of head injury. Eighty – three patients (43.0%) did not give history of any injury to the head. Twenty-nine patients were operated under local anesthesia while rest of 162 (84%) were operated under general anesthesia. On discharge 163 (84.5%) patients showed favorable outcome and 30 (15.5%) patients showed unfavorable surgical outcome out of them 13 patients died with a mortality rate of 6.7%.Conclusion: Chronic subdural hematoma is an important reversible cause of mortality and disability specially in elder patients. A favorable surgical outcome was observed when patients of chronic subdural hematoma were operated by two burrhole technique and assessed after three days of surgery. Mortality and morbidity of chronic subdural hematoma has decreased markedly in recent years because of improved diagnostic facilities, early surgical intervention, good and minimal invasive surgical procedures
Frequency of Post-Operative Cerebrospinal Fluid Leak after Infratentorial Surgery
Get PDFIntroduction: The infratentorial space (posterior fossa) is the region of the brain below the tentorium cerebelli and contains structures like of the midbrain, pons, medulla oblongata and the cerebellum. Cerebellopontine angle (CPA); an extra-axial region between the cerebellar hemisphere and the pons and is the site of exit for the cranial nerves 5th to 12th is also located infratentorialy. Primary brain tumors are commonly located in the posterior cranial fossa in children and approximately 54 – 70% of all intracranial tumors in children are infratentorial. Eighty-eight percent of all tumors fall into one of the 4 categories, astrocytoma, medulloblastoma, ependymoma and craniopharyngioma.Objective: The objective of the study is to determine the frequency of post-operative Cerebro spinal fluid (CSF) leak after infratentorial surgery.Material and Methods: This study was conducted at Department of Neurosurgery, PGMI Lady Reading Hospital, Peshawar. Duration of the study was six months and the study design was descriptive case series in which a total of 132 patients were observed by using 21.4% CSF leak11, 95% confidence level and 7% margin of error with the help of WHO software for sample size determination. More over consecutive non probability sampling technique was used for sample collection.Results: In this study 67% patients were in age range < 20 years, 20% patients were in age range 21 – 35 years, 10% patients were in age range 36 – 50 years while 3% patients were 51 – 60`years. Mean age was 22 years with a standard deviation of ±5.71. Fifty three patients were male and 47% patients were female. More over 7% patients had CSF leak.Conclusion: Our study concludes that the incidence of CSF leak after infratentorial surgery was 7% which give us an insight into our complication rate so that we should modify our surgical technique such as we can use fibrin glue or artificial dura in case our rate is hig
Patient Satisfaction Undergoing Surgery for Lumbar Disc Herniation
Get PDFObjective: To assess patient’s satisfaction, who are undergoing surgery for lumbar disc herniation.Materials and Methods: This observational study was conducted in Neurosurgery Department of Rehman Medical Institute, Peshawar from February 2014 to July 2014. A total of 58 patients who underwent surgery with lumbar disc herniation were studied. Clinical outcomes were measured using the visual analog scale (VAS) score for leg and/or back pain pre-operatively and 2 weeks post-operatively. Patient was considered satisfied from surgery (Lumbar Microdiscectomy), if there is improvement in VAS, 2 weeks post-operatively of ? 3 score. All the patients were followed up for a minimum period of four weeks.Results: The mean age of the patients was 40.21 ± 12.51 years with majority (62.1%) of the male patients. The main bulk of the patients (75.8%) having lumbar disc herniation were in between 20 – 50 yearsof age. Regarding level of the prolapsed intervertebral disc, most of the patients were harboring lumbar disc herniation at L4-L5 level (41.4%). About 5.2% (n = 3) of the patients were lost to follow-up. Major bulk of the patient (89.1%) was satisfied from the surgery. There was statistically significant difference between pre-op and post-op VAS (p value = <0.01).Conclusion: Majority of the patients of lumbar prolapsed intervertebral disc was male with L4 – L5 level most commonly involved.Almost 90% of the patients were satisfied from the surgery, Lumbar microdiscectomy, with statistically significant p value
Anterior Spinal Stabilization and Fusion in Cervical Spinal Trauma
Get PDFObjective: It was to find out the efficacy and benefits of anterior cervical spinal stabilization procedu-res in cases of cervical trauma.Material and Methods: It is a prospective study of 30 cases of Cervical Spinal Trauma in which anterior cervical spinal stabilization and fusion was performed. Study span is three years i.e from July 2005 to June 2008 with follow up period of one year and it was carried out in the Department of Neurosurgery, Quaid-e-Azam Medical College / Bahawal Victoria Hospital Bahawalpur.Results: 30 cases of cervical spinal trauma were included in the this study. Age range was 15 years to 40 years. Twenty three (23) were males and seven (7)) were females with male to female ratio of 3.2:1. Most common cause of cervical spinal injury was road traffic accidents and most common site of traumatic involvement was C5/C6 cervical spinal level. All the patients were belonging to poor and middle socio-economic class. Nine (9) patients sustained complete cervical cord injury and they were quadriplegic and remaining twenty one (21) patients were quadripretic as a result of partial cervical cord injury. All patients were assessed clinically and radiologically. Plain X-rays of cervical spine, AP and LAT. views, C-T scan and MRI of cervical spine were obtained to get information of injuries in detail. In almost all the cases, anterior two columns of spine were disrupted resulting in instability and cord compression. In all the cases cervical traction was applied to get alignment of the cervical column first and then anterior fixation and fusion was performed. All patients were mobilized early after surgery.Outcome: Nine (9) cases with complete cord injury did not improve neurologically after surgery. Eleven (11) patients with partial cord injury and power of G 3/5 before surgery improved to G 4+/5 after surgery and ten (10) patients with power G 2/5 before surgery improve to G 3/5 after surgery. All patients were out of bed early, to prevent the complications of being and ridden for long time.Conclusion: Anterior cervical spinal fixation and fusion is an excellent way of cervical spinal stabilization in cases of cervical trauma. Patients improve Neurologically with these procedures and they are mobilized early from the beds to prevent complications of being bed ridden for longer periods of time
Outcome of Endoscopic Third Ventriculostomy (ETV)
Get PDFObjective: To know the surgical outcome of endoscopic third ventriculostomy (ETV) in non communicating hydrocephalous.Materials and Methods: This cross sectional descriptive study was done in the department of neurosurgery PGMI / Hayatabad Medical Complex, Peshawar, from 2nd February 2011 to 1st march 2012. A total of 35 patients with non-communicating hydrocephalous, irrespective of gender discrimination were included in this study. Patients below two years of age and hydrocephalus with infected CSF or hemorrhage were excluded. Hydro-cephalous was diagnosed on CT scan brain. The information regarding patient demographical details, causes of hydrocephalus and complications of procedure were documented in patient’s Performa. The data was analyzed by SPSS version 17. Frequency and percentage was calculated for categorical variables. Mean ± SD was calcu-lated for age. Results were presented as tables.Results: A total of 35 patients with non-communicating hydrocephalous were included in the study. Out of 35 patients, there were 22 (62.8%) males and 13 (37.21%) females. The mean age was 21 years. Etiologically tuber-culous meningitis was the commonest cause of non communicating hydrocephalous. Post-operatively CSF leak-age was present in 3 (8.6%) patients, pseudomeningocele in 2 (5.7%) patients, transient memory loss in 1 (2.8%) and pneumo-cephalous in 1 (2.8%).Conclusion: The complications of endoscopic third ventriculostomy are transient. Those patients who meet the criteria, endoscopic third ventriculostomy offers the possibility of freedom from shunt dependency
Central Nervous System Complications in Civilians’ Blast – Induced Head Injuries
Get PDFObjective: To evaluate the frequency of central nervous system complications in civilians with explosive related head injuries.Material and Methods: This observational study was conducted at Neurosurgery Department, Post Graduate Medical Institute, Lady Reading Hospital, Peshawar – Pakistan, from January 2009 to December 2011 (3 years). We included all the patients with explosive related head injuries who were hospitalized, of all age groups and both genders, and excluded those patients who died before hospitalization. We also excluded patients with head injuries having neurovascular complications or had neurological deficit.Results: We had total of 191 patients with bomb blast head injuries treated in Lady Reading Hospital. One sixty six (86.9%) patients were male and 25 (13.1%) female with male / female ratio of 6.6:1. Their age ranged from 2 months of 71 years. Almost 65% of the patients were in their 2nd, 3rd and 4th decades of life. The common CNS complications in our patients were infections (12.04%), cerebrospinal fluid (CSF) leak (8.38%), epilepsy (5.2%) and post-traumatic hydrocephalous (3.7%). Mortality rate was 11%.Conclusion: We conclude from this study that central nervous system infections are the common (12.04%) complication of civilian explosive related head injuries followed by cerebrospinal fluid leak, seizures and hydro-cephalous respectively. Over all morbidity is 29.32% and mortality rate is 11% in those head injured patients who reach to hospital