The Availability and Utilization of Minimally Invasive Techniques (MITs), in Neurosurgery in Pakistan

Background: Minimally invasive techniques (MITs) have transformed the landscape of neurological surgery, offering a paradigm shift to patient safety, recovery speed, and surgical precision.   Objectives: This article explores the availability and utilization of these techniques, highlighting their benefits, advancements, and regional variations in practice. The primary goal of this study is to facilitate the adoption of advanced Minimally Invasive Techniques (MITs) in neurosurgery at hospitals in Faisalabad. Methodology: A complete methodology, keeping the said purpose in mind, is designed to bring a pragmatic shift of advanced minimally invasive techniques in neurosurgery to the healthcare system of Faisalabad for improved patient care and surgical outcomes. A total of two District Headquarters Hospitals, DHQs, and two private hospitals are selected in Faisalabad. The sample of N=100 neurosurgeons, technicians, support staff and hospital administrators selected randomly.   Results: The study revealed significant differences in the adoption and attitudes towards minimally invasive techniques (MITs) across public and private hospitals, with private hospitals showing higher adoption of advanced surgical methods. Factors such as equipment costs, training programs, and institutional support were key barriers influencing MIT utilization. The statistically significant differences in factors influencing MIT adoption underscore the need for targeted. Conclusion: The study highlights that while both public and private hospitals show positive attitudes toward the adoption of MITs, various barriers such as high equipment costs, insufficient training, and lack of institutional support hinder widespread adoption. Public hospitals are more reliant on traditional surgeries, whereas private hospitals are leading the adoption of advanced surgical techniques

Spinal Cord Injury and Pregnancy: Obstetric Challenges and Neonatal Outcomes

Objective:  Pregnant women with spinal cord injury (SCI) can have severe obstetric and neonatal challenges. However, there is limited literature on this population. Therefore, the objective of this study is to understand the obstetric and neonatal outcomes in these highly specialized individuals. Materials and Methods:  This study was conducted at the Punjab Institute of Neurosciences (PINS) and the Department of Obstetrics and Gynecology, Lahore General Hospital, Lahore (LGH). A sample of 25 women who appeared with SCI during pregnancy at PINS were recruited in this descriptive study for data collection. Later, their pregnancy and neonatal outcomes were observed at the specified department of LGH. Descriptive statistics were computed for quantitative and qualitative variables. Results:  The average age of these SCI patients was 28 ± 5.2 years. Most of the women (72%) got SCI during motor vehicle accidents (MVA). Thirteen women got SCI during their first trimester and faced severe complications like termination (12%) and miscarriages (12%) of pregnancies. Thoracic spine injury is the most common type of injury. Further, a Cesarean section was also adopted in 58% of cases, highlighting the potential challenges associated with SCI. A very high (42%) preterm birth rate was also reported in this unique sample. Conclusions:  This study is a unique combination of gynecological and neurological aspects. The majority of the pregnancy outcomes are successful with medical support, however, a significant number of miscarriages and termination of pregnancies were also observed. Understanding these outcomes can aid healthcare professionals in improving prenatal and postnatal care and such SCI patients

A Month in Cross Section: A Case Series of Eleven Sphenoid Wing Meningioma’s: A Single Center Experience

Introduction:  Sphenoid wing meningiomas represent 20% of supratentorial meningiomas. The tumor usually involves the visual pathway, the anterior vasculature, and cavernous sinus invasion. A higher morbidity, mortality, and recurrence are documented in comparison to meningiomas in other locations. Materials & Methods:  11 cases of joint global sphenoid wing meningiomas were operated in September 2022. Patient demographic, clinical, radiology, and per-operative salient features were noted. Post-operative clinical outcomes included improvement in visual acuity, neural deficit, and headache. The extent of resection on radiology plus survival was noted as an outcome measure. Results:  Patients aged 28 to 65 years, with 9 females and 2 males had giant sphenoid wing meningioma. Complete medial sphenoid wing involvement along with neurovascular structures, post-operatively they had visual deterioration, hence, the extent of resection was limited to prevent greater post-operative morbidity. 3/7 undergoing GTR had complete carotid artery encasement, in which full thickness MCA infarct was noted in 6 hours’ post-operative scan, they were later converted to a full 16 cm decompressive craniotomy. One survived with hemiparesis and aphasia while two died – a male (49y) and, a female (65), both left craniectomies. STR was done in four patients, with cavernous sinus invasion and internal carotid encasement. Conclusion:  Giant sphenoid meningioma involving the medial sphenoid wing and associated neurovascular structures is surgically challenging and must be treated with STR. If GTR is to be attempted, early CT Brain postoperatively to prevent mortality

Rare Brachial Plexus Tumor: Case Report and Surgical Management Insights from Pakistan

A 40-year-old male presented with a six-month history of numbness, paresthesia, and progressive flaccid weakness that was localized to the right C5 dermatome. A large, lobulated, and encapsulated mass in the medial aspect of the right axilla was identified via imaging studies. The mass was associated with the superior and middle trunk of the brachial plexus and extended to the supra and infraclavicular fossa. The imaging studies were supported by the nerve conduction studies (NCS), significantly highlighting the involvement of the right upper trunk with signs of denervation. The transclavicular neurosurgical approach was effective in the removal of the tumor while preserving the normal neurological functions. Brachial plexus tumors are rare and often underdiagnosed due to nonspecific symptoms and overlapping features with other neuromuscular conditions. This case highlights the diagnostic value of MRI and nerve conduction studies in identifying tumor characteristics and planning surgery. A transclavicular approach enabled safe excision with preservation of neural function. Postoperative recovery was favorable, with improved motor and sensory function and no recurrence at two months. This case emphasizes the importance of early diagnosis, appropriate surgical technique, and multidisciplinary management in achieving optimal outcomes. This case report highlights the diagnostic and therapeutic challenges associated with brachial plexus tumors due to their complex anatomical location. However, Imaging studies, a multidisciplinary approach, and nerve conduction studies were important in achieving favorable outcomes. The transclavicular neurosurgical approach was meaningful in tumor excision while preserving normal neurological function

Micro-bleedings of Cerebrum and Leukoaraiosis: Magnetic Resonance Imaging-Based Correlation Analysis by Micro-Bleed Anatomical Rating and Fazekas

Objectives:  Using Fazekas and Micro-bleed Anatomical Rating Scales (MARS) to assess the inter-relationship of MB(C) and leukoaraiosis based on magnetic resonance imaging (MRI). Materials and Methods:  Cross-sectional observational research was carried out at the radiology department of RYK Hospital Rahim Yar Khan, Pakistan. The study involved 70 participants who had MRI brain scans and were discovered to have micro-bleeds. The Micro-bleed Anatomical Rating scale (MARS) was used to grade micro-bleeds and Fazeka’s scale was implied for grading leukoaraiosis. The relationship between MARS and Fazeka’s scale was ascertained by Spearman's correlation. Results:  The patient's mean age was 65 years and 2 months, with male to female gender ratio of 1.8:1. A significant correlation (p<0.001) was observed between micro-bleeds grading of MARS and Fazekas grades, with a significant correlation coefficient of 1. Cerebral micro-bleeds also correlated with coexisting diseases, notably hypertension (84.28%), diabetes (60.00%), and smoking (55.71%). MRI analysis showed micro-bleeds were most frequently in variable locations (44.6%), followed by lobar regions (27.7%), deeper areas (18.5%), and basal nuclei (9.2%). Conclusion:  Leukoaraiosis (LA) and MB(C) have a strong correlation that suggests micro-blood vessel ischemia and hemorrhage as ultimate outcomes

Clinical Outcomes of Transforaminal Full Endoscopic Discectomy in the Management of Upper Lumbar Disc Herniation: A Prospective Study

Objective:  This study analyzes the clinical effects and possible adverse events that occur after performing Full Endoscopic Lumbar Spine Surgery (FELSS) through the transforaminal approach when treating upper lumbar disc herniation. Methods:  This prospective study recruited patients with Upper Lumbar Disc Herniation (ULDH) who underwent transforaminal full Endoscopic Lumbar Spine Surgery at the Farooq Endoscopic Spine Institute, Afridi Medical Complex, from February 2020 to January 2023, with a 1-year follow-up. Those patients who have Symptoms refractory to at least six weeks of conservative management, including physiotherapy, analgesics, and epidural steroid injections, were included. Visual analogue scale and Oswestry disability index were the main outcome measures used, along with reporting the complications. Results:  During postoperative months 1, 6, and 12, the patients experienced significant VAS and ODI score enhancements, which reached 1.5 ± 0.6 VAS and 12.5 ± 5.0 ODI (p < 0.001). Of the patients, 83.1% managed to return to work, and daily activities were resumed by 89.2% of the population. Three patients (6.38%) showed drastic improvements as they were pain-free and achieved standing position, while preoperatively they were brought on a wheelchair. The surgical procedures resulted in four complications affecting 2.4% of patients through dural tear, as well as 4.2% developing epidural hematomas. Conclusion:  The transforaminal FELSS surgical method represents a reliable and protected strategy to treat upper lumbar disc herniation while producing considerable positive treatment results. Surgeons can expect better patient recovery when medical treatment occurs soon after symptoms start and the patient has no neurological issues

Risk Factors for Postoperative Spinal Infections Following Instrumented Spine Surgery: A Case-Control Study of 500 Cases

Objective:  Postoperative spinal infections are a significant complication of instrumented spine surgery, contributing to increased morbidity and healthcare costs. This case-control study aimed to identify the risk factors associated with postoperative infections in patients undergoing instrumented spine surgery. Materials and Methods:  We carried out a retrospective case-control study involving 500 patients who underwent instrumented spine surgery at Lady Reading Hospital, Peshawar, between January 2019 and December 2023. Among them, 50 patients (10%) developed postoperative infections and were categorized as the case group, while the remaining 450 patients without infections formed the control group. Data were collected on sociodemographic characteristics, comorbidities, surgical factors, and postoperative care. To identify independent predictors of disease, we applied multivariate logistic regression analysis. A p-value of less than 0.05 was considered statistically significant. Results:  Diabetes mellitus (OR 3.5, p = 0.01), prolonged surgical time (>3 hours) (OR 3.1, p = 0.02), obesity (OR 2.9, p = 0.03), and insufficient antibiotic prophylaxis (OR 2.6, p = 0.04) were significantly associated with postoperative infections. Extended hospital stay was recorded in patients having post-operative infection or multiple readmissions, and reoperation was high. Conclusion:  Factors like diabetes mellitus, extended duration of surgery, obesity, and Failure to appropriately use prophylactic antibiotics may contribute to an elevated risk of infections following surgery. Recognizing these risk factors early and modifying them can reduce the burden of postoperative infection

Comparative Analysis of Complications in Meningitis Patient Tuberculous vs. Bacterial

Objective:  This comparative analysis aims to evaluate the patterns of radiological complications in bacterial meningitis against those seen in tuberculous meningitis. Materials and Methods:  A retrospective review of imaging and clinical data was conducted. The frequency of complications such as hydrocephalus, infarcts, tuberculomas, abscesses, and cerebritis was analyzed in both cohorts. Results:  Hydrocephalus was significantly more frequent in TBM (46.9%) compared to ABM (23%, p < 0.001). Tuberculomas were exclusive to TBM (57.3%, p < 0.001), while abscesses (6.3%) and subdural collections (8.4%) were unique to ABM (p < 0.05). Infarcts occurred at similar rates in both groups (27% vs. 28.1%, p = 0.88). Logistic regression identified TBM as an independent predictor of hydrocephalus (OR: 3.4, 95% CI: 2.1–5.8,p < 0.001) and tuberculomas (OR: 18.7, 95% CI: 11.4–30.9, p < 0.001). These findings emphasize the distinct radiological complication patterns in ABM and TBM, aiding in tailored management strategies. Conclusion:  The use of regression analysis provided new insights into predictors of complications; while cerebral infarcts are common in both ABM and TBM, TBM showed a greater burden of complications, particularly hydrocephalus and tuberculomas. The findings highlight the importance of early diagnosis and tailored treatment strategies to reduce morbidity and mortality in both forms of meningitis

Comparative Diagnostic Performance of CT and MRI in Acute Ischemic Stroke: A Retrospective Analysis From A Tertiary Care Center

Objective:  This study sought to assess and juxtapose the diagnostic proficiency of non-contrast CT and MRI in acute ischemic stroke, focusing on infarct delineation, hemorrhagic conversion, and posterior circulation involvement. Materials and Methods:  This retrospective observational study was conducted at the Department of Radiology, Lady Reading Hospital, Peshawar. A total of 200 patients aged 18 years or older, presenting with clinical suspicion of AIS, were included. All patients underwent both non-contrast CT and MRI within 24 hours of symptom onset. Imaging was reviewed independently by two experienced neuro-radiologists. Data on infarct detection, infarct volume, posterior circulation involvement, and hemorrhagic transformation were recorded. Results:  MRI detected acute infarcts in 92% of patients, significantly more than CT (66%) (p < 0.001). In posterior circulation strokes, MRI identified 60 cases versus 24 on CT (p < 0.001). Detection of hemorrhagic transformation was similar between modalities (CT: 87.5%, MRI: 85.7%; p = 0.68). MRI showed higher diagnostic accuracy with a sensitivity of 92%, specificity of 87%, and AUC of 0.95, compared to CT (sensitivity: 66%, specificity: 81%, AUC: 0.75). MRI also identified larger infarct volumes (p < 0.01). Conclusion:  MRI provides superior diagnostic performance in acute ischemic stroke, especially for early and posterior circulation infarcts, while CT remains crucial for initial hemorrhage exclusion. A combined approach may enhance diagnostic accuracy and improve outcomes in stroke care

The Comparison of Outcome of Traumatic Brain Injury in Left and Right Hemispheres of The Brain

Objective:  Using the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS), this study compares the clinical presentation, surgical requirements, and functional results of unilateral LH versus RH TBI. Materials & Methods:  Patients with unilateral LH or RH TBI were the subjects of a retrospective observational study. Individuals with bilateral, brainstem, or diffuse axonal injuries were not included. Initial GCS scores, imaging results, surgical procedures, and GOS scores at discharge were among the data gathered. To evaluate the variations in the clinical trajectory between the two groups, a comparison study was conducted. Results:  The findings showed that patients with RH injuries needed surgery more often than those with LH injuries and had substantially lower first GCS scores. Lower GOS scores at discharge were linked to RH injuries, even if the radiological findings were identical. On the other hand, LH injuries could be found more quickly and easily, which frequently resulted in better results and faster medical treatment. RH deficits' mild, frequently nonverbal character may cause a delay in diagnosis and treatment, which could worsen the prognosis. Conclusion:  Hemispheric laterality is important for TBI presentation and results. RH injuries are associated with worse healing, most likely because of delayed diagnosis and care. Understanding these hemisphere-specific variations better could facilitate early detection and direct more efficient, customized treatment plans