Pakistan Journal Of Neurological Surgery
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Maternal Concepts and Practices of Antenatal Care in Patients with Spinal Dysraphism
Get PDFObjective: To know about the antenatal care practice and concepts of the mothers who are having child with Spinal Dysraphism.
Materials and Methods: This was a cross sectional study conducted in the Department of Neurosurgery, Lady Reading hospital Peshawar between July 2013 and January 2014 (seven months). All patients who were having a spinal dysraphism were approached and history was taken from the mother or chaperon. The patients included all who presented to the out patients clinic, those admitted for surgery, and who had a surgical complications like the tethered cord syndrome. The patient's name, gender, address, age of the mother, maternal views about antenatal care, time of first antenatal visit if any, history and time of folate intake, number of total children and the serial number of the child affected. Other variables like socio-economic status, educational status of the mother was also noted. The data was entered and analyzed using SPSS version 17 and was expressed in tables and charts.
Results: During the study period 67 patients' particulars were noted. The age range was from 3 days to 12 years, there were 36 males and 31 females with a male to female ratio approaching nearly 1:1. The mother's age range was from 18 to 43 years and the socioeconomic status was low income in 43 patients. 23.73% of mothers have no idea of antenatal care, 34.32% mothers were not having any history of antenatal care, and only 22.38% were having a prenatal visit in the first trimester of pregnancy. 25 mothers were not having history of folate intake and only 8 (11.94%) were having positive history of taking in the first trimester. 18/67 (26.86%) of the affected children were the first child and the rest were the second or third.
Conclusion: none of the mother had enough knowledge and practices to prevent MMC. The first antenatal visit and folate intake was not at proper time to prevent MMC. If the woman with children been advised about folate intake, at least a third of the patients been prevented, since in majority it was the second child affected.
Abbreviations: MMC: Myelomeningocele. HC: Hydrocephalus
Pattern of Presentation of Backache and Association between Profession and Age with Backache; Study Conducted in Tertiary Care Hospitals; Karachi
Get PDFObjectives
To study presentation of backache.
To find out association between profession and age with backache.
Materials and Methods: This cross sectional study was conducted in the department of Neurosurgery and Urology , Baqai University Hospital Karachi and department of Neurosurgery Abbasi Shaheed Hospital Karachi from Feb 2015 to Dec 2017. It was non probability purposive sampling consisting of 100 cases. All consecutive low back ache patients from 15 to 60 years along with those with known cause for low backache related to other specialty and remained well after subsequent expert’s management were included while terminally ill patients were excluded.
Results: There were 35 males. Mean age of the patients was 44 years with SD 13, minimum 15 and maximum 80. In females 66% were house wives. Seventy six cases exhibited typical pain. Mean duration of pain was 2.7 months with SD three, minimum one and maximum 24. Most prevalent risk factor was obesity (22%). Straight leg raising sign was positive in 37. Degeneration was the most common finding in x-ray back (26). Mostly (51) exhibited moderate pain. Forty four were dealt with non-surgical /conservative management. 67% cases had DM and the same percent hypertension. The most common finding in MRI/CT was muscle spasm (37%). Eight patients had associated small renal stones. Out of these two had stone size of 0.8 cm and 1.0 cm, remaining six had less than 0.4 cm size. No association was found between profession and backache (p = 1.02) while that between age group and backache was significant (p = 0.005)
Conclusion: Profession was not significantly associated Intensity of backache However age group was significantly associated with pain intensity.
Abbreviations: ESWL: Extra Corporeal Shock wave lithotripsy. CT: Computer Tomography. MS: Metabolic Syndrome. BMI: Body Mass Index. QoL: Quality of Life. SD: Standard Deviation. MRI: Magnant Resonance Insulin
A Life Threatening Problem in Children; Extra Dural Hematomas. Analysis of 65 Cases
Get PDFAim: We present this study about the management of Extra Dural Hematomas in children using aggressive diagnostic approach, Prompt surgical intervention was the goal to get excellent results. Material and
Methods: Sixty five children underwent surgery in our department from Jan. 2010 to Dec. 2014. Data was gathered in terms of age, sex, mode of injury, clinical presentation, CT scan finding, and localization of hematoma, operative treatment and outcome.
Results: Out of 65 cases 44 (68%) were boys and 21 (32%) were girls with a ratio of 2:1. Age ranged from 1–18 years with majority 48 (64%) were from 6 – 18. Most common mode of injury was fall 35 (54%) followed by RTA 25 (38%). The commonest clinical presentation was altered sensorium 42 (63%) followed by headache and vomiting 36 (54%). Mortality rate was 4 (6%).
Conclusion: As early symptoms in children with EDH are quite non-specific, EDH must be considered in any child whose condition does not improve rapidly following a relatively mild head injury. Early diagnosis and emergency surgical treatment of EDH result in excellent outcome
Outcome of Ventriculo-Atrial Shunt as a Third Option in the Treatment of Hydrocephalu
Get PDFObjective: The purpose of this study is to describe outcome of ventriculoatrial shunt as a third option in the treatment of hydrocephalus.
Design: Descriptive case series study.
Place and Duration of Study: Neurosurgery department Peoples University of Medical and Health Sciences Nawabshah, from January 2013 to December 2015.
Materials and Methods: This study was conducted on patients who have already attempted for VP shunt and ETV and both have failed. Under radiological guidance distal end of catheter was placed in right atrium at D6 level. Jugular vein was cannulated via common facial vein or direct puncture.
Results: Over a period of 3 years, 24 patients were operated for VA shunt. There were 16 (66.66%) males and 8 (33.33%) females. Male to female ratio was 2:1. Age groups included 2 years to 18 years (mean 9.17 median 8 SD +/- 5.55). Mostly left side was used and common facial venesection was preferred to direct puncture of jugular vein. One patient developed shunt nephritis which was managed with Vancomycin.
Conclusion: VA shunt can be used as third option in the treatment of hydrocephalus taking great care of its complications.
Abbreviations: ETV: Endoscopic Third Ventriculostomy. VCS: Ventriculocisternostomy. CSF: Cerebral Scleral Fluid
Use of Drains Versus No Drains After Burr-Hole Evacuation of Chronic Subdural Hematoma
Get PDFObjectives: To compare the recurrence of chronic subdural hematoma after burr hole evacuation with and without use of subdural drain.
Study Design: It was multicenter randomized control trial.
Setting: Department of Neurosurgery, SKBZ/CMH Muzaffarabad, Department of Neurosurgery, Lahore General Hospital Lahore.
Duration: This study was conducted between June 2017 to December 2017. Inclusion Criteria: Male and female 18-80 years and chronic subdural Hematoma with midline shift of more than 5mm on CT scan.
Exclusion Criteria: Bilateral chronic subdural hematoma on CT scan, recurrent CSDH, patients with CSF shunt in-situ, patient with bleeding disorders (INR > 2.5, BT > 7 min, platelet count < 60000) or on anticoagulant drugs, patients with severe systemic ailment like renal failure (Serum Creatinine > 2.5), chronic liver disease (ultrasound shows liver cirrhosis and splenomegaly) and uncontrolled diabetes (BSF > 126) and known ischemic heart disease were excluded from this study.
Materials and Methods: In this study, 80 patients were included and randomly divided into two equal groups. Patient fulfilling the inclusion criteria were included in the study through the emergency and outdoor. All Patients were prepared for the surgery and informed consent was taken from all patients. All patients were treated in exactly the same way as per standard ward routine practice except that the treatment option (whether to use the drain or not) was decided through randomization; Group A with drain and Group B without drain. All patients were discharged at 3rd post op day and followed for six months.
Results: There were only 16 (20%) patients in which recurrence occurred. Out of these 16 patients 4 (25%) belong to drain group while 12 (75%) belong to without drain group. While in 64 (80%) patients no recurrence was observed [group A: 36 (56.25%) vs. group B: 28 (43.75%)]. The difference between both groups was insignificant, (p-value = 0.235).
Conclusion: It was concluded form the results of this study that there is no significant difference between both groups and recurrence will occur whether drain would be placed or not but it was also noticed that rate of recurrence was lower with subdural drain than without drain after burr hole evacuation of chronic subdural hematoma. Some other factor may be involved for recurrence so a long study is required to reach proper conclusion
Outcome of Two Treatment Regimens in the Management of Intracranial Fungal Granuloma
Get PDFObjective: Two treatment regimens means either you have to completely/near total excise the granuloma with sinus clearances (extra-dural) OR don’t touch it, even minimal invasive procedure such as burr hole biopsy can be fatal (intra-dural).
Introduction: The diagnosis of intracranial fungal granuloma almost always remained a challenge for neurosurgeons because of their rarity, alter behavior and lack of diagnostic tools. These infections are now easily diagnosed because of increased awareness and understanding regarding this pathology, better diagnostic tools and an increase in immunocompromised/immunocompetent hosts (from any cause). Most often, the fungal granulomas are due to contiguous spread of the infection from the paranasal sinuses and ear. Rarely, they may be due to hematogenous spread from a focus in the lungs. The infection can spread from sinuses to invade the brain parenchyma. Once it involves the brain parenchyma then the course of the disease is fulminant. Contrast enhanced C.T. and MRI of brain are investigations of choice. Although morbidity and mortality from central nervous system (CNS) mycosis has improved over years; mortality often reaches 75 – 100% despite an intensive treatment strategy (surgery followed by antifungal medications). Fungal hyphae are better demonstrated on periodic acid Schiff and Gomorimethanamine silver stain. This study will help us to describe an improved management approach to such patients with intracranial fungal granuloma depending upon the extent of spread, whether extradural or intradural. If the granuloma is extradural, the better management is extensive surgical approach with sinuses clearance followed by antifungals remains the gold standard. If the granuloma is intradural, then surgery is abandoned/ avoided to the extent possible.
Study Design: Case series.
Setting of Study: Department of Neurosurgery, Lahore General Hospital, Lahore.
Duration: One year from June 2012 to July 2013.
Materials and Methods: Twenty patients of intracranial fungal granuloma were included in this study.
Results: The mean ± SD age was 33.76 ± 5.43 years. Out of total 20 patients, most of the patients 10 (50%) were in age group between 20 – 30 years, 6 (30%) were between 31 – 40 year, and 3 (15%) patients were between 41 – 50 years. Only 1 (5%) patient was in age group of 51 – 60 year. There were 12 (60%) male and 8 (40%) were female patients. Thus the male to female ratio was 1.5:1. Out of total 20 cases, there were 18 (90%) patients had Aspergillosis type and only 2 (10%) patients had Mucormycosis type of fungal infection.
Conclusions:
According to the two treatment regimens, whenever the granuloma is intradural/ intraparenchymal surgery is avoided/ abandoned but when the granuloma is extradural a more aggressive surgical approach is planned.
In our study most of the patients were within the age range 20 – 30 years of age with a mean age of 33.76 years with male to female ratio of 1.5:1.
There were 90% of patients of aspergillosis and only 10% patients of mucormycosis.
Abbreviations: MRI: Magnetic Resonance Imaging. CT: Computed Tomography. CNS) Central Nervous System
Percutaneous Vertebroplasty for Osteoporotic Vertebral Compression Fracture
Get PDFObjective: To assess the safety and efficacy of percutaneous vertebroplasty in the treatment of single level Osteo-porotic Vertebral Compression Fractures (OVCF). Study Design: This was a case series study. Place and Duration of Study: Department of Neurosurgery Unit I, Lahore General Hospital, Lahore from Jan-uary 2012 to January 2014.Methodology: All 57 patients received PVP in the current study. Feasibility of a unilateral approach was judged before surgery using the 64 – slice helical computed tomography (CT) multiplanar reconstruction technique, a 3D accurate puncture plan was then determined. The skin bone distance, puncture angle and needle insertion depth were recorded during surgery. 2D CT rechecking was performed for any complication at day 1 after operation. Preoperative and postoperative numerical data were compared patients fulfilling the inclusion criteria were given time in the out – patient department for vertebroplasty. Patients who had a neoplastic etiology (meta-stasis or myeloma), infection, neural compression, traumatic fracture, neurological deficit, spinal stenosis, severe degenerative diseases of the spine or previous surgery at the involved vertebral body were excluded from our study. Prior to vertebroplasty the patient’s level of pain was recorded by using the visual analogue scale method: a scale of 0 – 10, with 10 indicating the most pain. After vertebroplasty, patients were asked whether their pain was completely relieved, partially relieved, unchanged, or worse. The post vertebroplasty visual analogue scale score were recorded on the day of vertebroplasty immediately after the end of the procedure and at 24 hours and then at the follow up visits at 2 weeks, 1 month, 3 months, 6 months, and 1 year intervals. Results: In this study there were 20 (35.1%) male and 37 (64.9%) female patients. The mean age of patients was 59.12 ± 12.40 years with minimum and maximum age 39-88 years respectively. On pre procedure assessment, fractures of L1, L2 and L3 were seen in 10 (17.5%), 6 (10.5%) and 5 (8.8%) respectively while T11 and T12 were seen in 6 (10.5%) and 16 (28.15%) respectively. Mean pre and postoperative pain on VAS was 7.91 ± 1.17 and 1.17 ± 1.45. After surgery mean difference in pain score was 6.73 ± 1.90 with fulfillment of normality assumptions (Kolmogorov-Smirnov Z = 1.18, p-value = 0.123). On applying paired sample t-test significant improvement in pain was found after surgery, t=26.71, p-value < 0.001. Mean cement volume and vertebral collapse was 6.42 ± 1.60 and 29.29 ± 4.19 respectively.Conclusion: Vertebroplasty is safe and effective procedure for osteoporotic vertebral collapse and its a day care procedure and can be performed safely under local anaesthesia
MRI Features of Intracranial Fungal Granuloma Taking Histopathology as the Gold Standard
Get PDFObjective: To explain the MRI features of intracranial fungal granuloma in patients with histopathology confirmed fungal infection.
Material and Methods: This descriptive case series study was conducted at the department of Radiology and Neurosurgery Lahore General Hospital, Lahore from June 2012 to June 2014, two years duration. 40 patients with histopathology confirmed intracranial fungal granuloma were included in this study. The mean ± SD was 33.76 ± 5.43 years. Out of total 40 patients 24 (60%) male and 16 (40%) female patients.
Study Design: Descriptive Case Series.
Duration: Two Years from June 2012 – June 2014.
Setting: Department of Radiology and Neurosurgery, Lahore General Hospital, Lahore.
Introduction: The diagnosis of intracranial fungal granulomas almost always remained a challenge both for neurosurgeons and radiologists because of their alter behavior and radiology. The diagnosis of these infections has increased in recent years because of increased awareness among clinicians about this pathology, better diagnostic tools and increase in the number of immunocompromised hosts (from any cause). Although mortality and morbidity from central nervous system (CNS) mycosis has improved over years; mortality often reaches 80 – 100% if the disease is not diagnosed properly and management initiated at the earliest. This study will help us to describe different radiological features (MRI) of this disease so that early detection and better management can be initiated on time.
Results: This study included 40 patients having histopathology confirmed diagnosis of intracranial fungal granuloma. The mean ± SD was 33.76 ± 5.43 years. Out of total 40 patients 24 (60%) male and 16 (40%) female patients. Thus the male to female ratio was 1.5: 1. Most of the patients were in their second and third decade of life. Out of total 40 cases, there were 36 (90%) patients had Aspergillus type and only 4 (10%) patients had Mucormycosis type of fungal infection.
Conclusion: These infections are hypo – iso intense on T2W MRI images with no or minimal enhancement in immunocompromised individuals. In immunocompetent individuals these infections form granuloma and usually show post gadolinium MRI enhancement.
Abbreviations: MRI (Magnetic Resonance Imaging), CNS (Central Nervous System)
Endonasal Endoscopic Repair of Cerebrospinal Fluid Leaks
Get PDFObjective: To assess the outcome of Endonasal Endoscopic Repair of Cerebrospinal Fluid LeaksMethods and Materials: This study was conducted from July 2013 to October 2014 at the department of Neurosurgery, PGMI, Lahore General Hospital, Lahore. A total of 20 patients were included in this study of both gender (male and female) and in the age range of 15 – 65 years. All the patients undergone Endonasal Endoscopic with the use of a Karl Stortz rigid endoscope of 0º and 30º with a 4mm diameter. All of them were followed up for recurrence of CSF leak and any postoperative complication.Results: Out of 20 patients, there were 08 (40%) males and 12 (60%) female patients. Their age ranged from 15 – 65 years. The maximum numbers of patients were in their third and fourth decade of life. The cause of CSF leak was spontaneous in 11(55%), iatrogenic in 5 (25%) and traumatic in 4 (20%) of cases. In 13 (65%) patients, CSF rhinorrhea was from right nostril and in 7 (35%) patients left side was affected. Endonasal Endoscopic CSF repair was done in all patients and was successful in 18 (90%) of patients. Two patients (10%) presented with recurrence of CSF leak in which one was successfully re-operated endoscopically and other undergone transcranial approach. Overall the success rate was 95% in our study. Only one patient complicates with meningitis postoperatively which was resolved with antibiotics.Conclusion: The repair of the CSF rhinorrhea by Endonasal Endoscopic surgery is minimal invasive, safe, effective and is a valid alternative to the cranial approach.
Abbreviations: CSF: Cerebrospinal Fluid. MRI: Magnetic Resonance Imaging
Comparison of Outcome in Microdiscectomy V/S Conventional Discectomy
Get PDFObjective: To Compare surgical outcome of microdiscectomy V/S Conventional Discectomy.
Study Design: Experimental Randomized Controlled trail.
Place and Duration of Study: This study was carried out in Department of neurosurgery Lahore General Hospital Lahore Duration of Study was Six Months followed by Six Months Follow up.
Sample Size: Forty Patients for herniated Laumber Disc were Divided into two Group of 20 Each.
Results: Mean age of Patients range from 18 to 70 years in Group A (Open Discectomy) out of 20 Patients, 14 Patients (70%) stayed < 5 days and 6 Patients (30%). Stay in Hospital > 5 days. In Group B 20 patients (100%). Hospital Stay < 5 days. C.S.F leak in group A 5%. In group B No. CSF leak recorded in Group A 4 Patients (25%) wound infection. In Group B, 1 Patient (5%) wound infection.
Conclusion: Both techniques are equally good and effective but in term of hospital stay and wound infection microdisectomy showed better results than open discectomy