Pakistan Journal Of Neurological Surgery
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Analysis of Head Injury Patients and Review of 100 Cases of Motor Bike Accidents
Get PDFObjective: The authors show the prevalence of head injury with special emphasis on mechanism of head injury, different age groups affected and its impact on society.Materials and Methods: Retrospective and prospective study conducted over a 6 months period. In this study, 3851 patients with head injury were assessed who presented in casualty outdoor department of our hospital. All age groups were included. The data from collected from patient’s medical record and severity of injury was assessed through Glasgow coma scale.Results: A total of 3851 cases were included in the study. Road traffic accidents remain the most common cause of head injury accounting for 2703 (70%) of cases, motor bike accidents were responsible for 1890 (72%) head injury among all cases of road traffic accidents while 408 (15%) were car accidents were among all 3851 cases, males were 2705 (70%) and females were 1148 (30%). Most common age range was 11 – 45 years having 2311 (60%) patients followed by patients above 45 years 962 (25%) and children 0 – 10 years of age 578 (15%) cases.Among 100 consecutive cases of motor bike victims were studied and almost exclusively male population was found to be affected. Age distribution analysis age less than 13 years 5 (5%) cases, 13 to 25 years accounted for 55 (55%) cases and above 25 years included 40 (40%) cases. There were only 4% wearing helmets while 96% were without helmets. Severity of injury sustained in all cases of head injury was GCS 15 – 15 3080 (80%) GCS 9 – 13 in 1385 (10%) and 3 – 8 GCS in 385 (10%) cases. Among motor cycles 55 (55%) cases were between the age of 13 – 15 years was mild head injury the head injury was 55 (55%) cases, moderate head injury 30 (30%) cases and severe head injury was 15 (15%). The type of head injury sustained was depressed fractures in 15% cases, epidural hematoma was found in 8% cases, subdural hematoma in 12% of cases, contusions in 10% while the rest of scans were normal.Conclusion: Motor bike accidents are the most common cause of head injury and strict implementation of traffic rules and media awareness may help to reduce incidence of head injuries
Effectiveness of Endoscopic Third Ventriculostomy in the Treatment of Obstructive Hydrocephalus
Get PDFIntroduction: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid in the ventricles of the brain that is or has been under high pressure. It results in raised intracranial pressure and compressive effects of vital brain structures that can be lethal if not treated in time. Various treatment options had been tried over the years but ventriculoperitoneal shunt has been the most common treatment option. As ventriculoperitoneal shunt is associated with obstruction, infection and over drainage, endoscopic third ventriculostomy has been used to avoid these complications.Objective: To determine the effectiveness of endoscopic third ventriculostomy in the treatment of obstructive hydrocepalus.Material and Methods: This is a descriptive study that was conducted in the Department of Neurosurgery Lady Reading Hospital Peshawar from October 2010 to October 2011. In this study all patients who underwent endo-scopic third ventriculostomy of more than six months were included. Total of 94 patients were included in the study. Effectiveness of the procedure was measured in terms of improvement in clinical condition i.e. GCS, head-ache, vomiting.Results: Total of 94 patients were included of which 58 were male and 36 were female. Age ranged from one to 70 years, with 50% of the patients were below 10 years of age. Majority of the patients had hydrocephalus due to space occupying lesion making 71.9% of the whole. In 75.5% of the patients the procedure was effective. Effecti-veness had no statistically significant difference in different age groups, however procedure is more effective in hydrocephalus due to space occupying lesion.Conclusion: Endoscopic third ventriculostomy is a very effective procedure for the treatment of obstructive hydrocephalus. It is effective irrespective of the age of the patient and cause of obstruction
Neurosurgical Management of Intracranial Epidermoid
Get PDFObjective: Epidermoid cyst or cholesteatoma is a congenital slow growing lesion. The objective was to analyze clinical presentation surgery and outcome after surgery.Study Design: Retrospective observational study.Materials and Methods: This study represents a retrospective review of patients treated with epidermoid cyst, during a period of 18 years between 1995 to 2012. It was conducted at the department of Neurosurgery Sheikh Zayed Hospital, Rahim Yar Khan and department of Neurosurgery PGMI / LGH Lahore and department of Neurosurgery AMDC Farooq Hospital, Lahore.Results: The age of our patients ranged from 18 to 40 years, with male predominance. The predominating symptoms were related to the 5th, 7th and 8th cranial nerve and headache. Our study included 10 cases of epidermoid cysts; four of them were in CPA area, two suprasellar region and one was at pineal region. It was not always possible to determine if the signs and symptoms were due to local involvement by the epidermoids, increased intracranial pressure or both. The age of our patients ranged from 18 to 40 years, with male predominance. The retrosigmoid approach was used in 5 patients, ® Frontal craniotomy in 2 cases, Rt interhemispheric transtentorial approach in one patient and sub-temporal approach in one case. Parental portaline approach in 1 case. Total resection of epidermoid cyst was accomplished in 7 cases. To minimize recurrence, the residual epidermoid was carefully coagulated with the aid of microscope and bipolar diathermy without damaging surrounding neurovascular structures.Conclusion: Surgical management of intracranial dermoid has encouraging and good results. Use of endoscope is good adjunct for complete removal of epidermoid from angles and corners of the lesion
Effectiveness of Discectomy for Pain Control in Lumber Radiculopathy
Get PDFObjective: To know about the effectiveness of discectomy for pain control in lumber radiculopathy. Material and Methods: This prospective observational study was conducted in Neurosurgery Department PGMI Lady reading Hospital Peshawar from May 2013 to April 2014. All patients admitted with Lumber radiculopathy and undergone discectomy for it were included in the study “while excluding myelopathy” and recurrent lumber radiculopathy. Patients age, gender, level of radiculopathy, pre operative symptoms, post operative improvement and deterioration in pain based on visual analogue scale were recorded on a designed Proforma. Patients were followed post-operatively for a minimum of 6 months. Data was entered and analyzed using SPSS version 17 and expressed in the form of tables and charts. Results: Total 84 patients were include in this study in which males were 51 (60.7%) and females 33 (39.3%). Based on levels of lumber radiculopathy L2 – L3 cases were 1 (1.2%), L3 – L4 3 (3.6%), L4 – L5. 31 (36.9) and L5 – S1. 49 (58.3%), Regarding age of the patients majority of the patients were in 3rd Dec. 23 (27.4%) and 4th Dec. 37 (44.0%) while 5th Dec. 20 (23.8%) and above 5th Dec. were 4 (4.8%). While pre operative low back-ache associated with lower limb pain corresponding to the radiculopathy was present in all patients (100%). Post operatively back pain was relieved in 72 (85.71%) and leg pain in 82 (97.61%) cases while back ache and leg pain were not relieved in 12 (14.29%), 2 (2.29%) successively (at the end of 6 months). Conclusion: Lumber radiculopathy due to prolapsed intervertabral disc occurs most commonly at L4-5, L5 – S1 in young to middle age peoples and discectomy is cost effective and safe procedure for it if done by experienced hands
Timing of Surgery as a Predictor of Outcome in Traumatic Acute Subdural Hematoma
Get PDFObjectives: To determine if reducing the time from trauma to surgery is associated with decreased mortality in patients with traumatic acute subdural hematomas. Background: It remains controversial whether decreasing the time from trauma to surgical intervention is associated with increased survival in patients with traumatic acute subdural hematomas. Materials and Methods: This is a prospective study of 8 months from August 2013 to April 2014 conducted at the Department of Neurosurgery, PGMI / Lahore General Hospital, Lahore. Adult patients in whom surgical evacuation of acute subdural hematoma was carried out were included in the study. Age / Sex, presenting Glasgow Coma Scale (GCS) and the time passed from trauma to the start of the surgery was noted. The outcome of the patients was categorized according to the Glasgow Outcome Scale.Results: Forty eight adult patients meeting the inclusion criteria were included in the study. There were 36 males and 12 females. The mortality for patients operated within four hours was 83.3% compared to 75% for patients operated within four to ten hours, and 73.1% for patients operated after ten hours. Two patients (12.5%) in the four to ten hour group, and five patients (19.2%) in the group of patients operated after ten hours had a favourable outcome. Surprisingly, this showed a trend that increased time from trauma to surgery led to a better outcome. However, patients operated early also had more severe neurological injury.Conclusion: A shorter time from injury to surgical evacuation does not decrease mortality in traumatic acute subdural hematoma
Management Outcome of Extradural Hematoma
Get PDFObjectives: To determine the frequency, clinical presentation and surgical outcome of extradural hematoma in head injury patients admitted in tertiary care hospital.Material and Methods: This descriptive study was conducted in neurosurgery department of Hayatabad Medical Complex, Peshawar from 1st February 2010 to 30th January 2012. A total of 367 patients of head injury, from both genders without age discrimination were included. EDHs caused by bleeding diatheses or vascular malformations, post surgical EDHs and those requiring conservative treatment were not included in the present study. Diagnosis of EDH was confirmed by CT scan brain. Patients' data was documented in a structured proforma and analyzed in SPSS version 17. Frequency and percentage was calculated for categorical variables. Mean ± SD was calculated for age. Results were presented as graphs and tables.Results: Total 367 patients were included out of which there were 238 (64.85%) males and 129 (35.14%) females. The mean age was 31 ± 1.3 years SD. EDH was most common in the age range of 21 – 30 years (28%). Most of the patients179 (48.77%) had Glasgow coma scale (GCS) in the range of 13 to 15. The commonest presentation was headache i.e. 242 patients (73.11%) and 210 patients (63.44%) had vomiting as presenting complaints. The most common location for EDH in the present study was temporo-parietal region i.e. 113 (30.79%) followed by frontal region i.e. 99 (26.97%).Glasgow outcome score was used to measure the outcome. Outcome was good in 229 patients but predominantly these patients were in GCS 14 – 15 on presentation. Death occurred in 29 (7.90%) patients and 3 (.817%) patients remained in vegetative state. These patients had very low GCS and coning or associated parenchymal or systemic injuries were already present before their operations
The Effectiveness of Surgery for the Symptomatic Prolapsed Lumbar Intervertebral Disc
Get PDFAims and Objective: To know the effectiveness of surgery for the symptomatic prolapsed lumbar intervertebral disc in patients admitted in tertiary care hospital.Materials and Methods: Subsequent to the approval from the ethical review committee, this descriptive study was conducted in neurosurgery department, Hayatabad Medical Complex, Peshawar from April 2009 to March 2012. All the patients were consented before enrolling into the study. Only those patients were included in whom straight leg raising sign was less than 60 degree and prolapsed disc was at L4-5 or L5 – S1 MRI. Those patients in whom the disc was at multiple levels or there was previous history of spine surgery, evidence of lumbar stenosis and higher level discs patients were excluded from this study. History, examination and MRI lumbosacral spine was done in all patients. Procedure was done in prone position under general anesthesia. Laminectomy and discectomy was performed .Patients were allowed to sit and mobilized after 12 hours of surgery and discharged mostly on 2nd postoperative day. The collected information was analyzed in statistical package of social sciences (SPSS) version 16.Results: Out of 226 patients, 144 (63.72%) were male and 82(36.28%) were female. Mean age was 33.67 years with age range from 18–64. Most of the patients presented with leg pain i.e. n = 210 (92.92%) followed by back pain n = 190 (84.07%), numbness n = 181 (80.08%), motor deficit n = 30 (13.27%) and cauda equine n = 16 (7.07%). Post operatively only 14 (7.96%) patients had sciatica, backache was present in 110 (48.67%) patients, numbness in 150 (66.37) patients, motor deficit in 6 (2.65%) and cauda equine persisted in 7 (3.09%) patients. Commonest complication of the surgery was CSF leak which was present in 15 (6.64%) patients followed by discitis i.e. in 8 (3.53%) patients. Foot drop in 2 (0.88%) patients. Recurrent disc was seen in 18 (7.96%) patients.Conclusion: Surgery in appropriately selected patients gives excellent results. It gives early and rapid pain relief. Conservative trial should be exhausted before embarking on surgery
The Role of Intracranial Pressure (ICP) Monitoring in Severe Traumatic Brain Injury (TBI)
Get PDFThe management of patients with severe head injury is a prodigious task for any neurosurgical team. After the initial life support, the management plan of patient with traumatic brain injury rest on the findings of a cranial CT scan. The treatment options of TBI differ with severity of trauma. Osmotic diuretics in the acute phase can be helpful. Hyperventilation is a method to be used in conjunction with other options in certain situations. Normal values of intra cranial pressure (ICP) vary with age, being 10 to 15 mm Hg in an adult. Intra cranial pressure (ICP) values of 20 to 30 mm Hg shows mild intracranial hypertension, while sustained intra cranial pressure (ICP) values more than 40 mm Hg indicate life threatening malignant intracranial hypertension which should be lowered immediately. Measuring the intra cranial pressure of severe traumatic brain injury patients is now mandatory as it allows an effective and control way of lowering the raised ICP with very good outcome results.Objective: To adjust the ICP lowering mechanics according to the reading obtained via the ICP monitor in patients after severe head injury so as to minimize the need of ventilatory support and decrease the patients’ stay at hospital.1. To measure the value of ICP by using ICP monitoring in severe head injuries (GCS score below or equal to 8).2. To assess the outcome of the conservative measures in patients in whom ICP was monitored, on the basis of Glasgow Outcome Scale.Study Design: Prospective descriptive study.Setting: Department of Neurosurgery, Lahore General Hospital, Lahore.Duration of Study: One year from July 2012 to July 2013.Material and Methods: Thirty patients of traumatic brain injury were included in this study. ICP monitoring was done via Integra intra parenchymal Camino bolt and Integra ICP monitors.Results: Out of 30 patients, there were 21 (70%) male patients and 9 (30%) female patients.The male to female ratio was 2.33:1. In 20 (67%) patients the ICP ranged from 25-34 mmHg. There were 10 (33%) patients having ICP of 35 – 50 mm Hg. The mean intracranial pressure was 29.5 ± 6.96. The Glasgow coma scale of our patients was such that there were2 (6.6%) patients had GCS 5. In GCS 6 there were 20 (66%) patients. There were 3 (10%) patients who had a GCS of 7. In GCS 8 there were 5 (16.6) patients. The ventilation duration was 5 – 15 days. The frequency of hospital stay in our patients 10-30 days. There were 2 (7%) patients of Glasgow outcome scale of grade – I. In grade – II, there were 3 (10%) patients, no patient in Glasgow outcome scale grade – III. There were 10 (33%) patients in grade – IV while 15 (50%) patient were in grade – V. In the follow up cases, after 1 month, there were no patient in grade – I. There were 3 (10%) patients of GOS grade – II, in grade – III there were 4 (13%) patients, there were 8 (27%) patients grade – IV. 15 (50%) patients of grade – V. After 3 month, there was 1 (3%) patient in grade – I. There were 2 (7%) patients of GOS grade – II, in grade – III there were 2 (7%) patients, there were 10 (33%) patients grade – IV. 15 (50%) patients of grade – V.Conclusion: It is concluded that ICP monitoring is useful for improving the outcome of traumatic brain injury patients. Most of the patients were in young age. Majority of the patients had a low Glasgow coma scales. In our study most of the patients were male. In this study there is short duration of ventilation in patients and a short hospital stay in patients of TBI in which ICP is monitored and addressed promptly
Efficacy of Conservative Management with Anti Tuberculosis Treatment in Patients with Spinal Tuberculosis
Get PDFIntroduction: Spinal TB is a result of haematogenous dissemination from primary focus in lungs or lymph nodes. Most of the under developed and developing world is endemic with TB as these populations are poorly nourished, overcrowded and live in sub standard social conditions and TB being an infectious disease spreads and sustains well in these overcrowded settings. Spinal TB is a common pathology in developing countries like Pakistan. We present a cohort study on findings of conservative treatment in patients suffering from spinal TB.Objective: To determine the efficacy of conservative treatment (ATT) in TB spine.Material and Methods: A cohort study was conducted in Bolan Medical Complex, Quetta in a period of 4 years from 2009 to 2013. A total of 135 cases of spinal tuberculosis were selected. Patients with cervical and cranio-cervical, and sacral TB were excluded from the study and also patients with any malignancy and other associated chronic joint conditions related to back were not selected. Patients were confirmed as a case of spinal TB using standard laboratory and radiology diagnostics. The patients were treated with ATT and followed up for 9 months until the completion of therapy.Results: The average age of patients was 48.8 years. Both male (50.4%) and female (49.6%) were equal in proportion in this study. Lumbar region was more affected (71.1%) with TB spine. Almost all study patients (99.3%) were cured with ATT whereas 1 (0.7%) patient was managed surgically.Conclusion: ATT is effective in the treatment of spinal tuberculosis provided timely diagnosis and initiation of therapy
Surgical Outcome of Anterior Decompression, Grafting and Fixation in Dorsolumbar Caries Spine
Get PDFTo evaluate the surgical outcome of anterior decompression, grafting and fixation in tuberculosis of the dorsal and lumbar spine.Study Design: Retrospective study.Place and Duration of Study: Department of Neurosurgery Unit – I, Lahore General Hospital, Lahore, From Jan 2008 to March 2012.Materials and Methods: Patients with caries spine having compression over the thecal sac with neurological deficit and kyphosis were included in the study. Patients below 17 years and above 56 year of age; patients with bed sores and unfit patients for anesthesia were excluded from the study. Complete blood picture with ESR, X-ray Chest, X-ray of the relevant spinal level and MRI were done. All patients were treated with corpectomy, debri-dement, drainage of abscess and grafting followed by fixation with poly-axial screws and rods. All patients were assessed by ASIA Impairment Scale before and after surgery and with Bridwell grading after surgery.Results: Among 79 patients, 47(59.49%) Male and 32(40.51%) Female patients, mean age was 37.2 ± 3 years. The commonest involved level was the dorsolumbar junction 53.16% (N = 42). Backache, sensory motor deficit and deformity were main presenting complains. Anterior decompression and grafting followed by fixation with poly axial screw and rods were done in all patients who fulfill the inclusion criteria. Lower limb power improved to ambulatory level in 60% of patients with complete paraplegia and recovery was excellent in patients with partial weakness; only n = 2 patients (2.53%) deteriorated to a lower grade. There was no postoperative mor-tality and one patient had long ICU stay due to lung injury. All patients have pain at the intercostal area and graft donor site that were treated with analgesia.Conclusion: According to our study, corpectomy followed by grafting and fixation is safe and effective pro-cedure. Even those patients presenting with complete paraplegia showed improvement in motor power to ambu-latory level and those who had partial deficit showed excellent improvement