Pakistan Journal Of Neurological Surgery
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Trigeminal Nerve Compression (TGNC) Technique for the Treatment of Trigeminal Neuralgia; Study of 80 Cases in 10 Years
Get PDFObjective: To evaluate the outcome of compression technique of trigeminal nerve at the intracisternal part of 5th nerve for trigeminal neuralgia.
Methodology: This cross sectional study was conducted in Hayatabad medical complex, Lady ready hospital and Abasin hospital Peshawer from Jun 2004 to December 2014. After taking consent from the ethical committee all post operative cases of trigeminal neuralgia of compression technique with either gender were included while post operative cases of it due mass lesion in the brain were excluded. Patient’s particulars documentation were done in pre designed proforma. Post operatively patients were followed till to 1½ years. Results were analyzed by SPSS version 20 and presented in the form of graphs, charts and tables.
Results: Total 80 patients were included in this study in which males were 60 (75%) while females were 20 (25%) cases having males to females ratio of 2;1. All the patients were in the age range of 35 to 65 years with the mean range of 45.76 ± 9.6 SD. V2, V3 pain distribution was on the top having 33 (41.25%) cases followed by V2 in 19 (23.75%). post operative outcome till to 1½ years out of 80 Patients 77 (96.2%) were completely pain free while 3 (3.8%) patients developed recurrence in the same branch of trigeminal nerve and 1(1.25%) case of CSF rhinorrhea, otorrhea and facial nerve paresis along with deafness for each of the three.
Conclusion: Compression technique for trigeminal neuralgia is safe, simple and cost effective.
Abbreviations: TGNC: Trigeminal Nerve Compression. CBC: Complete Blood Count
Outcome of Severe Traumatic Brain Injury in Patients with or without Pre Hospital Care
Get PDFIntroduction: Traumatic brain injury (TBI) is the leading cause of death and disability worldwide in the young ones. A severe TBI not only affects the life of a patient and his family, but it is also a social and economic burden. Furthermore, the cost of fatal TBIs and TBIs requiring hospitalization, several of which are severe, account for 90% of the total TBI medical costs. The transportation of TBI patients to hospitals specializing in neurosurgical care is significant regarding outcome. The rationale of our study is that most sophisticated of emergency, operative, or intensive care units cannot reverse damage that has been set in motion by suboptimal protocols of triage and resuscitation, either at the injury scene or en route to the hospital. The quality of pre-hospital care is a major determinant of long-term outcome for patients with traumatic brain injury. Pakistan being a developing country traumatic brain injury patients have a poor outcome due to lack of structured pre-hospital care and availability of emergency neurosurgical care in all the hospitals. Pre-hospital care is the care provided by Rescue 1122 from the scene of trauma to emergency department of hospital in the form of airway management, fluids, oxygen inhalation, analgesia and pressure bandage for scalp wounds. This study delineate guidelines for management and supervision of these patients in terms of pre-hospital care based on their outcome in the form of mortality at four weeks follow-up.
Methods and Results: Patients were divided in to two groups (150 each) with and without hospital care. Mean age of the patients was 33.35 ± 13.56. Male patients were 231 (77%) and female patients were 69 (23%). The stratification of various modes of injury regarding road traffic accident was 243 (81%) while of fall was 57 (19.0%). There was a high mortality in these patients as 143 (47.7%) died and just 157 (52.3%) remained alive. Ninety one (63.6%) patients in without pre hospital care group and 52 (36.4%) patients with pre hospital care group died showing a significant difference in favor of pre hospital care.
Conclusion: Pre hospital care results in significant decrease in mortality in patients with severe TBI as compared to patients without pre hospital care.
Abbreviations: TBI: Traumatic Brain Injury. GCS: Glasgow Coma Scale. ICU: Intensive Care Unit. RTA: Road Traffic Accident
Effectiveness of Unilateral Approach for Bilateral Decompression in Lumber Spinal Stenosis
Get PDFBackground: Lumbar spinal stenosis is defined as “buttock or lower extremity pain, which may occur with or without low back pain, associated with diminished space available for the neural and vascular elements in the lumbar spine. Patients complain of neurogenic claudication that is compatible with a narrowing of the lumbar spinal canal. Conventional laminectomy is frequently associated with surgical failures, generally related to postoperative iatrogenic spinal instability. Other operative options that are less invasive, such as the bilateral laminotomy and, in particular, the unilateral laminotomy for bilateral decompression (ULBD), have been introduced during the past years.
Objectives: The objective of this study is to determine the effectiveness of unilateral approach for bilateral decompression in Lumbar spinal stenosis.
Methods: It was a Descriptive case series study conducted in the admitted patients of Lumbar spinal stenosis in the Department of Neurosurgery, Lady Reading Hospital, Peshawar, in six months duration. Total of 171 patients were enrolled in the study. Bilateral decompression through a unilateral approach was performed under general anesthesia by single expert neurosurgeon having a minimum of 5 years of experience. All the patients were followed up till 24 hours post operatively for the determination of effectiveness in terms of improvement in at least one grade of pain on visual analogue scale from baseline.
Results: In this study, 171 patients with Lumbar spinal stenosis were observed. Male to female ratio was 1.41:1. The study included age ranged from 40 to 78 years. Average age was 59.29 years ± 11.41 SD. Efficacy of unilateral approach for bilateral decompression in Lumbar spinal stenosis was found in 136 (79.53%).
Conclusion: Unilateral approach for bilateral decompression is the better option for the patients presenting with Lumbar spinal stenosis
Operative Findings during Microvascular Decompression in Patients with Idiopathic Trigeminal Neuralgia
Get PDFObjective: To know about operative findings during microvascular decompression for idiopathic trigeminal neuralgia. Material and Methods: This prospective observational study was carried out on 108 patients who had idiopathic trigeminal neuralgia at Neurosurgery Department of PGMI, Lady Reading Hospital Peshawar from Jan 2010 to dec 2012 with total 2 year duration. All patients who underwent micro vascular decompression for idiopathic trigeminal neuralgia with both gender and having age from 2nd – 8 th decades were included in the study. Patients’ operative findings were noted during MVD and were documented on predesigned Proforma. Data was analyzed by SPSS version 17 and represented in the form of graphs and charts. Results: 108 patients were operated for trigeminal neuralgia. Males were 64 (59.25%) and females were 44 (40.74%). Age ranged from 18 – 70 years, mean age was 44 ± 5 years. Right side was involved in 75 (70%) cases. In 106 patients (98%), a neurovascular conflict was found, the superior cerebellar artery (SCA) being the most common cause of compression in 86 (80%) patients. Regarding branches mandibular division (V3) was most commonly involved having 64 (59.25%) patients followed by maxillary (V2) 32 (29.62%) and ophthalmic (V1) division 8 (7.40%). After surgery complete pain relief was noted in 97 (90%) patients. Post operatively, nausea, vomiting and dizziness was noted in 18 (16.66%) cases, diplopia in 5 (4.62%), slight deafness in 4 (3.70%) cerebellum infarct 2 (1.85%), CSF leakage in 6 (5.55%), facial palsy in 8 (7.40%), and wound infection in 5 (4.62%) one of which subsequently died. Conclusion: Vascular compression of trigeminal nerve is most common cause of Idiopathic neuralgia. Superior cerebellar artery is the most common compressing vessel, found during Microvascular decompression
Incidence of Infection and Causative Organisms in Patients with Ventriculoperitoneal Shunting for Hydrocephalus
Get PDFObjective: To determine about the incidence of infection and causative organisms in patients with Ventriculoperitoneal shunting for hydrocephalus.
Materials and Methods: This retrospective observational study was carried out in the Department of Neurosurgery Lady Reading Hospital Peshawar, from Jan 2012 to Dec 2013 (one year). The medical record of all cases operated in last one year was checked from record room. Documentation was done according to Performa designed indicating age, sex, clinical features and type of microorganism. All patients of either sex and age with Previous Ventriculoperitoneal shunt surgery and Signs and symptoms suggestive of shunt infection were included in the study. While patients of previous Ventriculoperitoneal shunt with no signs and symptoms were excluded from the study. All the data were analyzed by SPSS 20 and results were represented in the form of graphs / tables.
Results: Total 82 patients were included in the study in which males were 50 (60.97%) and females were 32 (39.02%). All the patients were in the age range of 6 months to 75 years having mean age of 37.75 years ± 5 SD. 58 (70.73%) were in pediatric age group and 24 (29.26%) were adults. Regarding etiology congenital acquiductal stenosis was the leading cause in children’s having 22/58 (37.93%) and CNS tumors were the most common cause in adults having 10/24 (41.66%). Fever and vomiting were the most common mode of presentation with 66 (80%) cases. overall incidence of shunt infection was 12 (14.63%) in which the most common microorganism was coagulase negative staphylococci having 6/12 (50%) cases.
Conclusion: Shunt infection most commonly occur in children’s and coagulase negative staphylococci is the most common causative organism.
Abbreviations: CSF: Cerebrospinal Fluid
To Compare Aneurysmal Findings of CTA with Surgical Findings in Patients of Aneurysmal Subarachnoid Haemorrhage
Get PDFObjective: To compare aneurysmal findings of CTA with surgical findings in patients of aneurysmal subarachnoid haemorrhage.
Materials and Methods: This descriptive study was conducted in the department of Neurosurgery, Lahore General Hospital Lahore over a period of nine months from 10th November 2008 to 9th August 2009. Study comprised of thirty-five patients after fulfilling the inclusion and exclusion criteria. All computed tomography angiography (CTA) findings about aneurysmal site, size, side, shaper, neck, direction of fundus, detection perforators and vasospasm were noted by the researcher and compared with surgical findings.
Results: On CTA finding of aneurysms, there were 14 (40%) patients of small size (< 7 mm), 12 (34.3%) of large size (7 – 20 mm) and 9 (25.7%) of giant size (> 20 mm). In surgical finding, there were 14 (40%) patients of small size, 11 (31.4%) of large size and 10 (28.6%) of giant size. On CTA finding, there were 31 (88.6%) patients of sacular shape, 2 (5.7%) patients of fusiform shape and 2 (5.7%) patients of bilobed shape. In surgical finding, there were 29 (82.9%) patients of sacular shape, 2 (5.7%) patients of fusiform shape and 4 (11.4%) patients of bilobed shape. On CTA finding, there were 21 (60%) patients of narrow neck (< 2 mm) and 14 (40%) patients of wide neck (> 2 mm). In surgical finding, there were 17 (48.6%) patients of narrow neck (< 2 mm) and 18 (51.4%) patients of wide neck (> 2 mm).
Conclusion: It is concluded from this study that there is only minor difference exist between the CTA finding and intraoperative findings of aneurysm. This difference was seen in neck of aneurysm and perforators. In surgical finding the surgeon must be prepared for any unseen event about aneurysm, vessels and surrounding tissue.
Abbreviations: AVM: Arteriovenous Malformation. DSA: Digital Subtraction Angiography. CTA: Computed Tomographic Angiography
Comparison of Surgical and Medical Treatment in Patients with Haemorrhagic Stroke
Get PDFOptimal management of spontaneous intracerebral haemorrhage (ICH) remains one of the highly debated areas in the fields of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience minimally invasive techniques have shown greater promise. We present our experience of 46 patients who presented to neurosurgery, neurology, Medical, Surgical and allied specialties at SIMS/ Services Hospital Lahore with clinical and CT scan Brain based diagnosis of Haemorrhagic Stroke and comparison as per outcome between Surgical and Medically treated patients. This is an ongoing study.
Objective: To compare the outcome results of surgical and medical management of the Haemorrhagic Stroke patients.
Study Design: A prospective ongoing study.
Place and Duration of Study: SIMS / Services Hospital, Lahore December 2013 until July 2015.
Materials and Methods: 46 patients who presented to neurosurgery, neurology Medical Surgical and allied specialties at SIMS/ Services Hospital Lahore with clinical and CT scan Brain based diagnosis of Haemorrhagic Stroke.
Results: 46 Adults patients meeting the inclusive criteria were included in our ongoing study, 26 patients in surgical group and 20 patients in medical group as already described in Pie Diagram 1. Out of 26 patients in surgical group 5 patients expired (19%) and 21 survived (81%).
Conclusion: Optimal cure of spontaneous intracerebral haemorrhage (ICH) is highly debatable neurosurgical problem. Past studies on comparison between surgical intervention with best medical management failed to show a clear improvement. However recent studies of minimally invasive techniques have shown greater promise5 . There is at present no clear indication for the surgical removal of ICH in the majority of the patients, but with deteriorating level of consciousness, many surgeons would agree surgical removal as a life saving procedure.
Abbreviations: AHA (American Heart Society), AVM (ArterioVenous Malformation), GCS (Glasgow Coma Scale), ICH (Intracerebral Hematoma), IVD (IntraVentricular Drainage), SAH (Subarachnoid Haemorrhage), HTN (Hypertension), DM (Diabetes Mellitus, STICH (supratentorial intracerebral haemorrhage)
Spinal Tumours: - Experience at Mayo Hospital
Get PDFObjective: Spinal tumours are mostly benign, having devastating effects on patients in terms of patient’s dis-ability, morbidity and mortality. Depending upon their site, size and growth potential, they have different clinical effects on the patients. We are presenting a case series of 138 patients managed in neurosurgery department Mayo hospital from Nov 2011 to Sept 2014.metastatic bony spinal lesions were not included in this study . The objectives of my study are to determine: Types of spinal tumours treated in this setting. Common and differenti-ating clinical features among subjects, different locations of the same types and the role of microsurgery. Materials and Methods: It is a retrospective study. 55 Schawanomas, 34 Menengiomas, 15 Ependimomas, 06 Dermoids, 17 Astrocytomas, 07 Plasmacytomas, 02 Aneurysm bone cyst and 02 Teratomas were managed surgi-cally. Schwanoma and meningioma’s prevalence was more in cervical and dorsal areas. plasmacytomas mainly affected dorsal spine, astrocytomas and ependymomas hade different locations. Teratomas occupied conus medu-llaris. Multiple laminectomies and laminotomies were performed according to situation. Radical resections for intradural extramedullary and gross total debulking for intramedullary lesions, under high resolution Microscope was done. Post operative improvements and complications were noted. Results: A radical resection of these tumors results in a good long-term outcome, since the majority is histolo-gically benign. For intradural intramedullary tumours gross total debulking is more appropriate. Adjuvant radi-ation therapy should only be administered for the high grade or malignant tumor. Malignant tumors have a dismal outcome and surgery in these patients should be a conservative debulking. Open door laminotomies are preferable in intradural extramedulary lesions and does not cause post op spinal deformity. Conclusion: Radical surgery for spinal tumors with laminotomies gives good results in terms of patient’s func-tionality and spinal stability
Surgical Management of Spontaneous Supratentorial Intracerebral Hemorrhage
Get PDFObjective: Spontaneous supratentorial intracerebral hemorrhage has the highest morbidity and mortality of all stroke subtypes, and the role of surgery remains controversial. A prospective study was conducted to evaluate the role of surgery in patients with spontaneous supratentorial intracerebral hemorrhage and to identify the predictors of outcome after surgery. Study Design: Prospective, retrospective and observational study. Materials and Methods: This study was conducted at the department of Neurosurgery PGMI / AMC / LGH Lahore during a period of 10 months from March 2013 to December 2013. Adult patients in whom surgical evacuation of spontaneous supratentorial intracerebral hematoma was carried out were included in the study. Age / Sex, presenting Glasgow Coma Scale (GCS) and the volume and site of hematoma was noted. The outcome of the patients was categorized according to the Glasgow Outcome Scale.Results: Twenty six adult patients meeting the inclusion criteria were included in the study. Twenty out of the 26 patients died and the mortality was 77%. All the 17 patients with deep seated bleed had a poor outcome (dead or disabled). 1 of the 9 patients with superficial bleeds had a favourable outcome. The mortality of patients with GCS ? 8 was 87.5% compared to a mortality of 60% for patients with GCS ? 9. Best outcome was seen in patients with GCS ? 9 and a superficial bleed with 3 (75%) of the four patients surviving and 1 (25%) having a favourable outcome. The volume of the Intracerebral hemorrhage (ICH) did not effect the outcome. Conclusion: Deep seated bleeds do not benefit from surgical evacuation of hematoma. Improved outcome can be anticipated in patients presenting with superficial hemorrhages and GCS ? 9
Dysembryoplastic Neuroepithelial Tumour (DNET): A Rare Brain Pathology Presenting with Intractable Seizures
Get PDFDysembryoplastic neuroepithelial tumour (DNET) is a benign glioneuronal tumour often related with intractable localization – related seizures in both in paediatric age group as well as young adults. However, a small number appear to have the potential for malignant transformation. Total surgical removal without any adjuvant therapy is the gold standard treatment. We report a case in which DNET appeared in a 13 year old male. Cranial CT scan showed a discoid lesion with peripheral enhancement in right parietal lobe. Micro-decompression of the tumour was done. On histopathology, the tumour revealed features of WHO grade I dysembryoplastic neuroepithelial tumour