Timing of Surgery as a Predictor of Outcome in Traumatic Acute Subdural Hematoma

Objectives: 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

Short-Term Complications of Microscopic Trans Nasal Transsphenoidal Pituitary Adenomectomy

Background/Objective:   The commonest of pituitary gland tumors is pituitary adenoma which may be excised transcranially or trans nasal trans sphenoidal using either microscope or endoscope, in this study, the microscope was used. The objective was to see the short-term outcome of patients after microscopic transnasal trans-sphenoidal pituitary adenomectomy. Material & Methods:  This was a descriptive prospective study carried out from July 2019 to July 2021. 80 cases were included. All patients were investigated by contrast brain MRI, hormonal assay for pituitary gland & visual perimetry. Patients were evaluated for complications at 48 hours and 7 days. Results:  Mean age of the study population was 41.78 ± 11.75 years. There were 61 (76%) men & 19 (24%) women. 55 (68.8%) patients had functioning and 25 (3.3%) patients had nonfunctioning adenoma. Among 33 (41.3%) patients size of the adenoma was < 0.9 cm and 47 (58.8%) patients had adenoma > 1.0 cm. 12 patients had CSF leaks within 48 hours of surgery and 5 had a persistent leak on the 7th day. No statistically significant association was seen between age, gender, and size of adenoma and persistent CSF leak (P > 0.05). Diabetes insipidus was found in 9 patients. 3 had post-operative hematoma, 01 patient had meningitis and 2 patients died. Conclusion:  microscopic transnasal trans-sphenoidal surgery is a safe procedure yet associated with significant complications

Management of Postoperative Pseudomeningocele following Posterior Cranial Fossa Surgery

Objective: Pseudomeningoceles are common complications after posterior fossa surgery. Management guide-lines are lacking, and radically different suggested treatments varying from observation to immediate surgical intervention are encountered in literature. The purpose of our study was to detail our experience in the manage-ment of pseudomeningocele following posterior fossa surgery.Methods: A retrospective, single-center study was conducted on 137 patients who underwent elective posterior fossa surgery for a variety of diseases. Patients with post operative pseudomeningocele formation were initially treated with conservative measures including bed rest, head elevation, pressure dressing and CSF lumbar drain-age. Surgical re-exploration and repair of the dural rent was done in case the pseudomeningocele didn’t settle with these conservative measures. In patients having gross hydrocephalus on post-operative CT scan a VP (ventriculo-peritoneal) shunt was done in case the conservative measures failed.Results: There were 8 (5.8%) cases of pseudomeningocele formation after posterior fossa surgery. The pseudomeningocele didn’t settle with conservative measures in any case. Surgical re-exploration and repair of the dural rent lead to the settlement of pseudomeingocele in four cases. VP shunting for gross hydrocephalus on post operative CT lead to the settlement of the pseudomeningocele in the other four cases. Conclusion: Although it has been stated in literature that most cases of pseudomeningocele settle with conser-vative treatment with only a few requiring surgical intervention, our findings were different with conservative measures failing to resolve the pseudomeningocele in all the cases. We believe that it would be beneficial to take an aggressive attitude toward this condition and to consider the possibility of early surgical intervention more seriously

Diathermy Stimulation to Avoid Nerve Injuries during Trans-pedicular Screw Placement in Dorso-lumbar Spine

Objective: To demonstrate the utility of diathermy in avoiding nerve injuries due to misplacement of trans-pedicular screws (TPSs) during Dorso-lumbar spinal fusion.Study Design: Retrospective studyPlace and Duration of the Study: Department of Neurosurgery, Lahore General Hospital, Lahore, from Oct. – 2007 to Oct. 2012.Materials and Methods: In this retrospective study, diathermy was used to assess whether a screw deviated from the pedicle by observing synchronous leg movements caused by intermittently touching a diathermy to the pedi-cular instrument. Diathermy was performed in 159 cases in which 561 pedicle screws had been placed.Results: Leg movements were observed in 36 cases and the sensitivity of diathermy was 82.7%, the specificity of 98.6%. No neurological complications associated with the placement of pedicular screws were observed after adding diathermy stimulation to the conventional methods.Conclusion: Diathermy may be helpful to avoid nerve injuries during transpedicular screw placement

Surgical Outcome of Anterior Decompression, Grafting and Fixation in Dorsolumbar Caries Spine

To 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

Multidisciplinary Management and Outcome of Intradural Extramedullary Spinal Tumors

Introduction/Objective:  About fifteen percent of the primary CNS tumors are intraspinal. About two-thirds of tumors are intradural extramedullary (IDEM). This study was conducted to review the outcome of operative management of intradural extramedullary tumors in correlation with the factors, both clinical & histopathological, influencing the neurology of patients & prognosis. Materials and Methods:  It was a multicenter study including 42 patients conducted from December 2018 to December 2020. All patients were diagnosed by MRI with and without contrast. Patients were surgically treated & analyzed for clinical features i.e., pain by visual analog scale (VAS) & neurology by modified McCormick scale both preoperatively & post-operatively. Clinical features & outcomes were correlated with tumor size & histopathology. p-value < 0.05 was considered significant. Results:  This study included 42 cases. The most common diagnosis was schwannoma (76.19%). The average intradural space occupied at presentation was 82%. The most common location was dorsal (90.4%). The visual analog score for pain (VAS) improved in all patients post-operatively from 7 ± 1.9 to 2 ± 0.8 (p = 0.003) & modified McCormick scale from 3.0 ± 1.3 to 2.0 ± 1.0 (p = 0.005). The preoperative symptoms were correlated with the only size of the tumor occupying the intradural space (VAS p = 0.021, modified McCormick scale p = 0.018). Conclusion:  All the tumors excised showed some improvement in neurological status. Therefore, all patients diagnosed with IDEM should be operated on even if present with prolonged symptoms or severe neurological compromise. Keywords:  Intradural Extramedullary, Meningioma, Schwannoma, Intraspinal

Outcomes of Cranioplasty after Craniectomy

Objective:  Craniectomy is a widely used procedure in neurosurgery that results in more cranioplasties to repair skull defects. The complication rate after cranioplasties seems to be higher than elective craniotomies so this study was conducted to determine the outcome of cranioplasty after craniectomy. Materials & Methods:  The patients included in this study had craniectomy and cranioplasty for any indication. Patients included had variables, such as age, sex, underlying pathology, craniectomy and cranioplasty dates, the material used for cranioplasty (autologous bone or methyl methacrylate), and methods of cranioplasty flap fixation (sutures or titanium plates and screws) follow up period and complications. Results:  It was concluded that patients in the age group of 41 – 60 years (5 cases), males (7 cases), cranioplasty performed after 6 months (5cases) with autologous bone graft (8cases) were associated with more complications. Conclusion:  The overall rate of complications associated with cranioplasties is not negligible, however, early cranioplasty in young patients with the use of polymethyl methacrylate may be associated with less complication rate. Keywords:  Decompressive, Craniectomy, Cranioplasty, Autologous, Polymethyl Methacrylat

Neurological Outcome of Carpal Tunnel Decompression in Carpal Tunnel Syndrome

Objective: To evaluate the outcome of carpal tunnel decompression in Carpal tunnel syndrome. Study Design: Prospective and retrospective observational study. Materials and Methods: This study was conducted at the Department of Neurosurgery, PGMI / AMC / Lahore General Hospital, Lahore, during the period of 4 years from Jan. 2009 to Jan. 2013. All patients with symptoms and signs of carpal tunnel syndrome and with positive nerve conduction study were included in our study. Exclusion criteria was those unfit for surgery such as patients on warfarin and patient with mild symptoms treated with wrist splint and oral analgesic, diabetic, hypothyroid patient, patients in which nerve conduction study points to radiculopathy and patients with history of trauma with carpal bone fracture were excluded from study. Prospective clinical data collected included patient reported outcome measures and satisfaction scores, touch threshold, pinch and grip strength. Patients were assessed clinically, underwent nerve conduction studies and surgery as indicated. Baseline and one – year follow-up data were analysed for 57 patients (62 hands). Results: A total of 57 patients (62 hands) treated with surgery between Jan 2009 and Jan 2013 agreed to participate in the study. Complete data at baseline and 1 year were available for 57 patients (62 hands). There was significant improvement in all domains of the Boston Carpal Tunnel and Michigan Hand Outcomes questionnaires, grip strength and touch threshold. There were no adverse events. Eight patients (14%) requested advice on scar management or had queries regarding the duration of post-operative recovery of sensation and function. The total mean operating time was 12.8 minutes (range: 5–15 minutes) and the mean tourniquet time was 2.5 minutes (range: 1–11 minutes). Patient satisfaction as judged using a Picker questionnaire was very high. Conclusions: A highly efficient clinical service involving both diagnostics and treatment can be delivered through minimum hospital visit and day care surgery while maintaining optimal outcomes and high patient satisfaction

Analysis of Head Injury Patients and Review of 100 Cases of Motor Bike Accidents

Objective: 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

Normal Pressure Hydrocephalus: Selection of Patients for Shunt Placement

Objective: To determine the criteria in our setup, for patients with normal pressure hydrocephalus (NPH), based on clinical and radiological findings.Material and Methods: This is multiple center study, including departments of Neurosurgery at LGH, Lahore / KEMU, Lahore. Over 25 years, 240 patients were included purely on clinical criteria of poor memory, sphincter loss, gait apraxia and Evan’s ratio ≥ 0.30 on CT or MRI. All patients had shunting procedures.Results: Hundred and ninety patients were improved and all of them had significant reduction in Evan’s ratio i.e. ≥ 0.06. Only 10 patients had infection out of whom 8 lost to follow up while 2 had shunt revision.Conclusion: Shunting procedures especially VP shunt shows good results if selection is stringent and no co-morbidity is associated