Clinical Outcome of Percutaneous Radiofrequency Rhizotomy for Trigeminal Neuralgia at a Tertiary Care Hospital.

Background: - Trigeminal neuralgia is a disease typically characterized by involuntary attacks of lancinating pain in the distribution of the trigeminal nerve that are activated by non-noxious stimuli. Numerous anticonvulsants, either alone or in combination, remain the first choice in the medical treatment of trigeminal neuralgia.3If the disease becomes non responsive, there are numerous surgical options like micro vascular decompression or minimally invasive percutaneous lesioning of the trigeminal nerve, such as glycerol rhizolysis, Radiofrequency Rhizotomy, and balloon compression. Objective: - To determine efficacy of percutaneous Radiofrequency Rhizotomy for trigeminal neuralgia in terms of early pain relief in a tertiary care hospital. Methods: -  62 patients with refractory trigeminal neuralgia or lancinating, recurrent episodes of pain in the distribution of Ophthalmic (V1) and Mandibular (V3) branches of trigeminal nerve, not responsive to 6 months of conservative treatment were included. Study was completed in one year i.e. from March 2015 to Feb 2016. Result: - In our study population, 62 included patients were had mean age 56.08 ± 7.39 years. 44 patients (71%) were male. Our treatment was effective in 58 patients (93.5%) while there was recurrence among 4 (6.5%) only. Conclusion: - It is concluded that the efficacy of percutaneous Radiofrequency Rhizotomy for trigeminal neuralgia in terms of complete relief of pain with intact sensations in treated branch region is excellent (93.5%)

Outcome of Deep Brain Stimulation (DBS) for the Treatment of Parkinson’s Disease in Terms of Improvement in MDS-UPDRS Scale Over 5 Years

Background & Objective:  Parkinson’s disease (PD) is the second most common Neurodegenerative disorder after Alzheimer’s disease. There are several surgical procedures for advanced PD, but amongst all deep brain stimulation has proven to be safest and effective. The objective of this study was to see the outcome of DBS for the treatment of PD in terms of improvement in MDS UPDRS over 5 years. Material and Methods:  44 patients were included in study from Oct 2014 to Sep 2019. History, examination was carried out, and preoperative MDS-UPDRS (Movement Disorder Society Unified Parkinson’s Disease Rating Scale) was recorded. Postoperative improvement in MDS-UPDRS score was assessed at first Programming, 2nd week, and 6th week and at 3rd month. Results:  At baseline the mean, the MDS – UPDRS (Part-I) score was 14.20 ± 0.61 and at the end of 3rd month, the mean score was 11.18 ± 0.47 respectively. At baseline the mean, the MDS – UPDRS (part-II) score was 18.99 ± 0.70 and at the end of 3rd month, the mean score was 13.01 ± 0.57, respectively. At baseline the mean, the MDS – UPDRS (part-III) score was 45.19 ± 0.90 and at the end of 3rd month, the mean score was 25.15 ± 1.20 respectively. At baseline the mean, the MDS – UPDRS (part-IV) score was 10.18 ± 0.87 and at the end of 3rd month, the mean score was 3.85 ± 1.03, respectively.  Conclusion:  The Deep Brain Stimulation (DBS) is safe and effective in the management of PD

Anterior Cervical Discectomy and Fusion: Operative Technique and Post-Operative Complications – An Experience in a Tertiary Care Hospital

Background and Objective: The most common spinal procedure in our set up to address various disorders of the cervical spine like prolapsed intervertebral disc, trauma, and degenerative disc disease is an anterior cervical discectomy and fusion (ACDF). As there is no technique without complication, this procedure is also related with certain important complications. We evaluated post-operative complications of ACDF in our institution.Material and Methods: The preoperative data of 148 patients who were operated in last 3 years for ACDF isincluded in the study. Patients with previous neck surgery are excluded.Results: The most commonly performed surgical interventions is single level ACDF (65%). Dysphagia is mostsignificant (16%) complication. After which neurological deterioration (9%) with equal incidence of RecurrentLaryngeal Nerve Palsy and wound infection that is 8% each.Conclusion: The most common post-operative complications are dysphagia and worsening of preexistingneurology and multilevel ACDF is identified as the most common risk factor. Early recognition of complicationsand management may help to reduce mortality and morbidity

Insular Glioma Esoteric Precinct

Background and Objective:  The complex insular anatomy and its proximity to eloquent areas make this area almost inaccessible for safe surgical resection of Glioma. Aim of our study is to determine outcome assessment after surgical resection. Materials & Methods:  This was a retrospective analysis of 59 patients over a period of 5 years from July 2013 till June 2018. All patients of insular Glioma were included in our study irrespective of age and sex. Degree of surgical resection, Post-operative neurological deficits and complications were assessed. They were followed in the outpatient department at 3, 6 and 12 months. Results:  Total 59 patients were included 38 (64.40%) male and 21 (35.59%) females. 36 (61%) patients had right sided insular Glioma and 23 (38.98%) have left sided. Seizures were main presentation in 46(77.96%) patients. Trans-sylvian route adopted in 34 (57.6%) patients followed by transcortical route. Near total Resection was Possible in 30 (50.84%) patients and partial in 29 (49.15%) patients. Focal neurological deficits the motor weakness & dysphasia were main post-operative complications in 18 (30.5%) patients. Three (5.08%) patients died. In all grade II and grade III Gliomas no increase in size was discovered on MRI Brain at 6 and 12 months. Conclusion:  Maximum safe resection of insular Glioma with acceptable morbidity is possible with improved overall survival and disease free interval

Frequency of Improvement in Muscular Rigidity after Pallidotomy in Medically Refractive Parkinsonian Patients

Objective: To find out frequency of improvement in muscular rigidity after Pallidotomy in Parkinsonian patients who are medically refractory.Material and Methods: This prospective descriptive study conducted in Neurosurgical Unit II, Punjab Institute of Neuro-Sciences, LGH, Lahore, during the period of one year from March 2015 to February 2016. They were evaluated before admission by history and thorough examination and then investigated with a CT scan and MRI of the brain. This study included patients as young as 30 years to as old as 65 years. Those patients who had trauma, stroke, demyelination or lesion in basal ganglia were excluded from the study.Results: 75 patients were included in the study with no lost to follow up. At the time of presentation, baseline rigidity graded as 3 in 37 (49.3%) and grade 4 in 38 (50.67%) patients. Reduction in rigidity at ≥ 25%, was considered significant improvement. At 3 months follow up 49 (65.3%) patients had UPRDS grade 1 while 26 (34.7%) had (Unipied Parkinson’s Disease Rating Score) UPRDSS grade 2 and no patient shown UPRDS grade 3 or 4. Out of 37 patients who had UPRDS grade 3 at baseline, 32 had grade 1 while 5 had grade 2 after Pallidotomy. Out of 38 patients, who had UPRDS grade 4 at baseline, 17 had UPRDS grade 1 while 21 had UPRDS grade 2 after pallidotomy. The difference was calculated to be significantly high (p < 0.001).Conclusion: Pallidotomy is one of the successful surgical procedures to reduce Parkinsonian muscular rigidity

Outcome of Endoscopic Repair of CSF Rhinorrhea with Endonasal Endoscopic Approach in terms of Success of Repair.

Objective: This descriptive case series conducted to evaluate the outcome of CSF rhinorrhea repair with the Endonasal Endoscopic approach in terms of success of the repair.Materials and Methods: The study was conducted at Neurosurgery department, Unit II, Punjab institute of neurosciences, Lahore. This study involved 40 patients aged between 3-80 years of both genders diagnosed of CSF rhinorrhea with presented with in 1 week after trauma and spontaneous and postoperative cases.Results: The age of the patients ranged from 5 years to 53 years with a mean of 22.75 ± 15.59 years. Total 30 (75%) male and 10 (25%) female patients are included in the study. The underlying etiology was found to be post-traumatic (67.5%) 27 cases, followed by post-operative in 7 (17.5%) and spontaneous in 6 (15.0%) cases. Successful repair was observed in 36 (90.0%). No significant difference was found in the frequency of successful repair among various age groups; 5-20, 21-36 and 37-53 years (95.7%, 83.3% and 81.8%; p = 0.381), gender groups; male verses female (86.2% and 100.0%; p = 0.194) and etiological groups; post-traumatic vs. post-operative vs. spontaneous (92.6% vs. 71.4% vs. 100.0%; p = 0.169).Conclusions: The frequency of successful repair was found to be 90% in patients of CSF rhinorrhea treated through Endonasal endoscopic approach. No statistically significant difference was found in successful repair frequency across patient’s gender, age and underlying cause of CSF rhinorrhea

Range for Normal Body Temperature in Hemodialysis Patients and Its Comparison with That of Healthy Individuals

Background/Aims: Patients with chronic kidney disease undergoing hemodialysis have an altered homeostasis leading to altered body temperatures. We aimed to determine the range for normal body temperature in hemodialysis Patients and compared it to healthy individuals. Also, we determined how much axillary temperatures differed from oral temperatures in both groups and whether axillary temperature is affected by the presence of an arteriovenous fistula (AVF) in hemodialysis Patients. Methods: Oral and axillary (left & right) temperatures were recorded using an ordinary mercury-in-glass thermometer in 400 subjects (200 hemodialysis Patients, 200 healthy individuals) at the Sindh Institute of Urology and Transplantation from mid-May to mid-June 2006. Comparisons were made between the temperatures of both groups. Results: Mean oral temperature in hemodialysis Patients was higher than in healthy individuals [98.7 degrees F (37 degrees C) vs. 98.4 degrees F (36.8 degrees C), p \u3c 0.001], as was the mean average axillary temperature [97.7 degrees F (36.5 degrees C) vs. 97.5 degrees F (36.3 degrees C), p = 0.02] and mean left axillary temperature [97.9 degrees F (36.6 degrees C) vs. 97.6 degrees F (36.4 degrees C), p \u3c 0.001]. The fistula arm had higher axillary temperature in 77 (44%) hemodialysis Patients. The difference between oral and axillary temperatures varied widely, making it impossible to obtain an accurate correction factor in both groups. Conclusion: Hemodialysis Patients have higher normal body temperatures than healthy individuals. Axillary temperatures require cautious interpretation. In hemodialysis Patients, the non-fistula arm should be preferred for recording axillary temperatures, as the presence of AVF may cause discrepancies in temperature measurements

Outcome of Anterior Fusion Technique for Multilevel Cervical Spondylotic Myelopathy

Objective:   To asses’ surgical parameters, complications, clinical and radiological outcomes in the treatment of 2-, 3- and 4-levels Cervical Spondylotic Myelopathy . Methods: A total of 90 patients with 2-, 3- or 4-level CSM who underwent anterior decompression and fusion procedures between January 2017 and October 2018 were divided into three different groups, the 2-level group (65 patients), the 3-level group (20 patients) and the 4-level group (5 patients). The clinical and Radiographic outcomes like Neck Disability Index (NDI) score, hospital stay, blood loss, operation time, fusion rate, cervical lordosis, cervical range of motion (ROM), and complications were compared between different procedures. Results: At a minimum of 1-year follow-up, no statistical differences in NDI score, hospital stay, fusion rate and cervical lordosis were found among the 3 groups. However, the mean postoperative NDI score of the 4-level group was significantly higher than that in the other two groups , and in terms of postoperative total ROM, the 3- level group was superior to the 4-level group and inferior to 2-level group (P,0.05). The decrease rate of ROM in the 3-level group was significantly higher than that in the 2-level group, and lower than that in the 4-level group. Conclusions: As the number of involved levels increased, surgical results become worse in terms of operative time, blood loss, NDI score, cervical ROM and complication rates postoperatively. An appropriate surgical procedure for multilevel CSM should be chosen according to comprehensive clinical evaluation before operation, thus reducing fusion and decompression levels if possible

Analysis of Bilateral Stereotactic Pallidotomy in Patients Presenting with Generalized Dystonia

Objective: To find the improvement with stereotactic pallidotomy. The main aim of the study was to assess the outcome based on mean change in Burke-Marsden-Fahn Dystonia Scale (BMFDS) score after stereotactic pallidotomy in patients presenting with generalized dystonia. Material & Methods:  Quasi-experimental study was conducted over five years at Unit II, Department of Neurosurgery, Lahore General Hospital, Lahore. A total of 16 patients 9 were males and 6 were female meeting inclusion criteria of age 20-70years of either gender presenting with generalized dystonia for at least 6 months. Patients underwent stereotactic pallidotomy. Furthermore, Patients with coagulopathies (PT, apt > 4 sec deranged), Patients with a history of trauma, Patients with CVA (on history), and patients having intracranial pathology (trauma/hematoma) were excluded. BMFDS score was noted at baseline and after 3 months of surgery, and change in BMFDS was noted. The questionnaire was used to collect information. SPSS Version 21 was used to examine the data that had been gathered. Results:  The patients' average age was 47.35 and 14.40 years. There were 19 (31.67%) males and 41 (68.33%) females. The mean duration of dystonia was 15.43 ± 6.13 months. At baseline, the mean BMFDS was 49.67 ± 5.69 which was reduced to 18.03 ± 3.35. The mean change in BMFDS was 31.63 ± 6.38. There was a significant change in BMFDS (p < 0.05). Conclusion:  Hence, in patients with generalized dystonia, stereotactic pallidotomy is beneficial in lowering the BMFDS score by more than 50%

Outcomes of Microsurgical Resection of Low-Grade Cerebral Arteriovenous Malformations: A Descriptive Observational Multicenter Study from a Low-Middle-Income Country

Objective:  To appraise the overall outcomes of microsurgical resection of low-grade arteriovenous malformations (AVMs) in a low-middle-income country. Materials and Methods:  Data was collected from three different neurosurgical centers in Pakistan for this study and it lasted for two years. Patients who had been diagnosed with cerebral AVMs were categorized into three groups, A, B, and C, using the Spetzler-Martin (S-M) grading system. AVMs of grades 1 and 2 were included in Class A. Class B contained grade 3 AVMs, while Class C contained grade 4 and 5 AVMs. All male and female patients in Class A were eligible for this study.  Results:  There were a total of 22 patients. The mean age was 36.41 ± 14.32 SD years. There were 12 (54.5%) male patients and 10 (45.5%) female patients. 13 patients (59.1%) presented with spontaneous intracerebral hemorrhage, while 9 patients (40.9%) presented with seizures. 14 patients (63.6%) had S-M grade 1 and 8 patients (36.4%) had S-M grade 2. All patients underwent microsurgical resection. We discovered 4.5% morbidity in our study. There was no postoperative mortality. According to the Glasgow outcome scale, an excellent functional outcome of 95.5% at 6 months and a 100% cure rate were noted. Conclusion: Regarding morbidity, mortality, and cure rates for low-grade AVMs in our nation, microsurgery is a secure and efficient therapeutic option