DISTRIBUTION AND CHARACTERISTICS OF HEAD INJURY AND REFERRAL NUMBER AT DR H. ANDI ABDURRAHMAN NOOR GENERAL HOSPITAL, TANAH BUMBU, SOUTH BORNEO, INDONESIA

Background: Head injury (HI) has been one among leading causes of morbidity and mortality worldwide especially in the peripheries area. In South Borneo, 9.4% of trauma cases was a head injury. Especially, Tanah Bumbu Regency, one of peripheries area in South Borneo ranks third for head injuries after Tabalong and Tanah Laut Regency in 2007.Objective: The aim of this study was to describe the characteristics of head injury patient and referral number at Dr. H. Andi Abdurrahman Noor general hospital.Methods: All head injury patients admitted to the emergency department (ED) of Dr. H. Andi Abdurrahman Noor general Hospital in a one-year period (2017) were registered in this retrospective study. Using the total population sampling method, 413 cases of head injury during the period were included as a subject of study.Result: This study showed that mild head injury was the most cases of head injury with 325 cases (78.2%). 61 patients were referred to a higher trauma center in 2017. Head injury was most common in 11-20 years old age group. Men also had higher incident rate compared to women (2:1). Most of the patients were a nonstate employee. Head injury is commonly caused by traffic accident.Conclusion: This study shows that characteristics of HI in the peripheries area such Tanah Bumbu regency are no different from other countries. Our findings suggest that several prevention steps should be taken to reduce the number of head injury based on the distribution and characteristics of head injury sustainers

Delayed Treatment of Spinal Cord Injury In Young: A Case Report

Background: Spinal cord injury (SCI), one of the problems caused by traffic accidents, has a high morbidity in developing country like Indonesia. In Indonesia, the use of motorcycles is increasing every year. The epidemiological data from Fatmawati Hospital of spinal cord injury in 2014 was 104 cases both traumatic and non-traumatic SCI. In this case, a young boy with worsening of SCI, delayed the treatment for about 3 months.Case: A 19 years-old male complained of limbs paralysis for the past two weeks. He felt numbness and tingling in hamstring and calf areas. From past medical history, he had a motorcycle accident 3 months prior. After the accident, he suffered from extreme low back pain, but he could still move his legs. Due to economic restrictions, the patient refused to go to the hospital, and they chose a traditional treatment. For about three months, the pain was decreasing, but he was never pain-free. As the symptoms continued to worsen, the neurosurgeon decided to decompress the spinal cord and performed discectomy. After a week of treatment, the pain disappeared, motor muscle got better, and he could feel again the sensation on the dermatome of S1. Conclusion: Early treatment is recommended to get a better outcome. The surgery is not the only treatment, rehabilitation and orthotics using are important too. Delayed treatment increases morbidity rate

Analysis of Clinical Results of Three Different Routes of Percutaneous Endoscopic Transforaminal Lumbar Discectomy for Lumbar Herniated Disk

Objective: Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) can be performed by using foraminal, intervertebral, and suprapedicular routes. The aim of this study was to assess clinical results of three different routes of PETLD.Methods: One hundred and eleven patients who underwent PETLD between January 2016 and October 2016 were included in this study. PETLD was performed using the foraminal (group A), intervertebral (group B), and suprapedicular (group C) routes in 32, 46, and 33 patients, respectively. Outcomes were evaluated using the visual analogue scale (VAS), Oswestry Disability Index (ODI), and MacNab criteria.Results: Seventy-one men and 40 were women (mean age 53.33 ± 14.12 years). The mean follow-up period was 6.44 ± 3.26 months. The preoperative VAS score decreased significantly (P < 0.01) in all 3 groups, but the postoperative VAS score was higher for the foraminal route than the intervertebral (P<0.001) and suprapedicular routes (P< 0.001). Excellent outcome grade according to MacNab criteria was less in foraminal route (18.7%) than in intervertebral (52.2%) and suprapedicular (56.7%) routes. ODI improved significantly (P< 0.01) in all 3 groups.Conclusion: All 3 routes of PETLD resulted in good to excellent clinical results. Nevertheless, the postoperative VAS score was higher for the foraminal route than the intervertebral and suprapedicular routes, probably because of the neurologic characteristics of the disk location. The surgeon should consider this problem to alleviate pain postoperatively and to better counsel the patient before surgery

Endoscopic Access to the Ventral Thoracic spine: PETD vs. Thoracoscopy

Symptomatic thoracic disc herniation (TDH) is estimated to afflict between 1 in 1,000 and 1 in 1,000,000 people; affecting men more frequently than women, with the highest incidence seen at 40-50 years of age. TDH occurs at all levels of the thoracic spine but 75% of cases occur below T8, with T11-T12 being the most common site due to spinal mobility and weakness of the posterior longitudinal ligament.Manipulation of the thoracic spinal cord through the conventional posterior approach has been associated with poor outcomes. A conventional posterior approach consisting of laminectomy, cord retraction, and disc removal was historically done to treat TDH but this causes spinal cord injury and irreversible paraplegia due to cord manipulation on the relatively rigid spinal cord.The anterior approach to the spine is also intimidating to the spine surgeon due to the unique anatomy of the thoracic spine. Conventional open approaches to the thoracic spine involve a thoracotomy, rib resection, and corpectomy to view the spinal cord anteriorly. This has been associated with perioperative morbidity due to surgical site pain, difficult/painful breathing, shoulder girdle dysfunction, and wound healing problems.In order to spare the patients suffering from these postoperative iatrogenic sequelae, the author presents two different minimally invasive approach techniques; percutaneous endoscopic thoracic discectomy (PETD) vs. thoracoscopy, each applied to a different indication or thoracic pathology, to gain an enough but safe access to the ventral thoracic spinal canal through minimized surgical damages without yielding a postsurgical morbidity

Fear-Avoidance Beliefs in Chronic Cervical Zygapophyseal Joint Pain Relieve With Medial Branch Block

Background: Chronic posterior neck pain is common, affecting 50–75% of people for 1 year or longer. The zygapophyseal joint is reported to be one of most common causative factors. The fear-avoidance is a model that describes how individuals develop chronic pain as a result of avoidant behaviour based on fear. Previous studies shown that medial branch block (MBB) and radio frequency neurotomy were effective for intractable pain.Material And Method: Case 1, TMK, Male, 57 yo, left posterior neck pain, VAS neck 7-8, NDI 46 %, no radiating pain, no neurological deficit. FABQ-PA score showed high fear (60%). Physical examination provokes facet joint pain. Neuroimaging revealed facet degeneration on T1WI and T2WI MRI. Case 2, RDW, Male, 45 yo, left posterior neck pain, VAS neck 8-9, NDI 40 %, no radiating pain, no neurological deficit. FABQ-PA score showed high fear (63%). Physical examination provokes facet joint pain. Neuroimaging revealed facet degeneration on T1WI and T2WI MRI. Case 3, TAY, Female, 52 yo, bilateral posterior neck pain, VAS neck  8-9, NDI 52 %, no radiating pain, no neurological deficit. FABQ-PA score showed high fear (60%). Physical examination provokes facet joint pain. Neuroimaging revealed facet degeneration on T1WI and T2WI MRI.Results: Our study reveals that C-MBB might ensure pain relief and decrease analgesic need. Physical activity at 1-, 3- and 6-months post-CMBB intervention were 65%, 60% and 68% of patients, respectively, gained >50% pain relief.Conclusion: Therapeutic MBB may provide an option for chronic high fear-avoidance beliefs pain of zygapophyseal joint

SKULL-BASE MENINGOENCEPHALOCELE PRESENTING AS A LABIOGNATOPALATOSCHIZIS AND BILATERAL MACROSTOMIA ON IMPENDING PARTIAL AIRWAY OBSTRUCTION IN A NEONATE

A unique skull-base meningoencephalocele presenting as a labiognatopalatoschizis and bilateral macrostomia in a neonate is reported, with impending partial airway obstruction. Surgical management requires neurosurgical intervention and plastic reconstruction. This case report presented a term neonate was noted to have a soft, fxed, 5-cm mass fulled of his mouth with the impending partial airway obstruction. The patient had several episodes of apnea related to partial airway obstruction by the mass. Computed tomography (CT) scan showed a large complex cystic and solid mass on lamina cribrosa of ethmoidal bone. Focal calcifcation was seen within the mass. The mass extended resulting in the complete cleft of lip and palate, and bilaterally macrostomia. The brain on CT scan was normal with no dysmorphic structures. A transcranial approach by the neurosurgeon was performed to excise the cephalocele and close the dura mater. The bone defect on lamina cribrosa of ethmoidal bone was closed using periosteum tissue. The procedure was followed by total excision of the prolapsed brain tissue and osteotomy on the left palate and then nasal airway reconstruction continued with gradual reconstruction with external compression for close loopholes of the palate. Three months after the initial surgery, a defect of the palate was narrowing and without cranial nerve defcits. Skull-base transethmoidal meningoencephalocele with labiognatopalatoschizis and bilateral macrostomia is a rare congenital abnormality. Neurosurgical procedures through transcranial approach are safe and provide excellent results. Moreover, gradual reconstruction will improve a patient’s quality of life and activity of daily livin

Brachial Plexus Surgery

The magnitude problems of brachial plexus lesions are not only about the surgical approaches but also the basic problems. Its vague clinical symptoms, the complexity of anatomy structure, the use of advanced imaging followed by electrophysiology to address the lesions, and the challenging of surgical timing and options make those lesions management more challenging. These challenges in Indonesia are more difficult because not so many neurosurgeons are familiar with brachial plexus surgery.Brachial plexus surgery is in evolution. For brachial plexus nerve sheath tumours, a fascicular level resection of tumours and preservation of uninvolved fascicles is now possible. Neuropathic pain may be improved by a dorsal root entry zone lesion procedure. The timing of surgery is different in each pathology, especially in traumatic injury. In traumatic injury, it depends on several factors, e.g. the mechanism of injury, type of injury, the speed of the vehicle, and the mode of fall while victim lands on the ground.The common surgical options in traumatic injury are direct repair by means of an end-to-end suture, external neurolysis, nerve grafting, and nerve transfers. Secondary reconstruction to improve function has been widely introduced such as soft-tissue reconstruction (tendon/muscle transfer or free muscle transfer) and bone procedures (arthrodesis or osteotomy). Brachial plexus surgery demands a broad multidisciplinary approach to a common problem, targeting not only the peripheral nerve, but also the brain, spinal cord, muscle, end-organ, bone and joints, and their complex interactions.

Surgical Treatment for Scoliosis

Recently, patients with spinal deformities, particularly scoliosis, could be handled well through surgical pathways. Generally, surgery is indicated in patients with scoliosis curve exceeding 45 degrees (COBB angle> 45). The ultimate goal is to reduce the curve as optimally as possible without disturbing spinal cord. Whether the result is straight or not, it also depends on the patient's spine flexibility before surgery.Surgical indications are for improving appearance, preventing increasing degrees of the curve, preventing interference to other organs such as the lungs, and preventing neurological deficits. Correction of Cobb angle below 25 degrees had already makes the patient feel more comfortable. The amount of screw and instrumentation length depends on the number of spines involved. After surgery treatment, 2-4 weeks of rest are required before returning to daily activity.Fusion principle states that the spine will be slightly stiff in order to be corrected but it is believed that patient's activity could still be done with the remaining flexibility. Surgical treatment of scoliosis that does meet the indications is imperative and relatively safe with advances in medical technology today

Cervical Spine Trauma Management

The incidence of spine injury following accidents are still very high in developing countries. Many problems occur after the accident including primary intervention on the scene, transportation to the public primary hospital, the referral system, and finally, the management at the central hospital.Cervical spinal cord injuries represent 20-33% of total spinal injuries with the prevalence of the subaxial levels. In patients with a preoperative neurological deficit due to spine trauma, in case of spinal cord compression or instability, surgery is often the treatment of choice to grant a chance of neurological recovery, early mobilization, and faster return to usual daily activities compared to the conservative treatment. In the past, many authors suggested a delayed surgical treatment to reduce postoperative complications rate, but recent studies have shown that an early decompression (<72 h) may facilitate a postoperative neurological improvement probably due to the prevention of the secondary mechanisms of damage in acute SCI.In the context of the advanced management of spinal injuries, the main points of the focused assessment, the important waypoints of a full classification of the skeletal and spinal cord injury, the principles of early prioritization and decision making, the outline of the surgical strategy including indications, timing, approaches, technique and post-operative care, and the outline principles of rehabilitation. The authors in this paper try to summarize and create a guideline of management, based on experience in a regional centre

A PRELIMINARY STUDY ON THE EXTRAVASATION OF INTRAVENOUS CHEMOTHERAPY IN SANGLAH GENERAL HOSPITAL, BALI – INDONESIA

Background: Extravasation of intravenous chemotherapeutic agents is one of the most devastating complications, which unacceptable condition neither to patient nor to medical services. Many healthcare providers realize that even one extravasation injury is too many since this injury is preventable. Published incidence rates of chemotherapy extravasation range from 0,01% to 6%, but in our institution, chemotherapy extravasation was not well recorded, so the incidence rate is unclear and the number of injuries is underestimated. Method: We observed chemotherapy extravasation occurrence during a 6 months period in our institution, from September 2013 until March 2014. We recorded the chemotherapy agents, patient’s clinical presentations, and extravasation management.Result: During our observation, 1374 chemotherapies administered, and 10 cases of chemotherapy extravasation occur, particularly doxorubicine was the main chemotherapy agent. Almost all treated conservatively, only 10% handled with surgical management. Eventually, 20% of cases have implanted port placed.Conclusion: Extravasation of cytotoxic agents is a serious problem, it causes tissue damage, prolongs the length of stay, increases hospital cost and psychological damage to cancer patients who under chemotherapy. It preventable but always underestimate by some clinicians, the use of central venous access device is one of the solutions to minimize the damage.