Microsurgical Resection of Intracranial Dermoid and Epidermoid Tumors

Objective: To Ascertain the outcome of microsurgical resection of intracranial dermoid and epidermoid tumors.Materials and Methods: This prospective study was carried out in Neurosurgical Department, Lady Reading Hospital (LRH) Peshawar and followed for 3 years after microsurgical resection. All the patients with suspected intracranial Dermoid and epidermoid tumors (IDETs) on imaging study pre-operatively and later confirmedpostoperatively (after histopathology) were enrolled. Patients having recurrent tumor, opting for nonsurgical management and those deem unfit for surgery were not included in the study.Results: 27 patients were included in the study with 12 (44.4%) males and 15 (56.6%) female. Age of the patients rangefrom 11 to 58 years.Mean age was 38.6 years. Epidermoid tumors were 19 (70.3%) in number and dermoid 8 (29.7%) in number. The most common presentation was increased intracranial pressure (ICP) and cranialnerve deficit. The lesion was located in infratentorial location in 15 (56.6%) patients, 12(44.4%) were supratentorialy located. Gross total removal (GTR) was performed in 21 (77.8%) patients, while in six patients (22.2%) subtotal removal (STR) was attempted. 1 (3.7%) patient died while 2 (7.4%) patients had permanent morbidity post operatively, all other patients (89%) improved. Recurrence occurred in 9.5% of GTR patients while in STR patients, 33.3% patients were noted with increase in residual tumor on neuroimaging.Conclusion: Microsurgical resection with GTR is possible for most IDET and gives good results with minimalcomplications

Outcome of Anterior Cervical Discectomy with PEEK Cage Fixation for Single Level Cervical Disc Disease

Objective:  To assess the outcome of anterior cervical discectomy and fusion (ACDF) with PEEK cage. Material and Methods:  This prospective study was conducted in the Departments of Neurosurgery Prime Teaching Hospital and Irfan General Hospital Peshawar. Patients undergoing one level ACDF with PEEK cage fixation were enrolled in the study. Patients who needed multiple level ACDF or corpectomy with plating and redo cases were excluded from the study. A proforma, which included age, gender, address, level of prolapsed disc, sign and symptoms, pain score, MRI findings were filled. All patients were assessed on day of discharge and on follow-up visit after one month. Data was analyzed with SPSS version 22. Results:  Total 95 patients were included out of which 58 (61%) were male and 37 (39%) were female. Range of patients` Age was from 27 years to 64 years with 50.4 years mean age. Most patients (65%) had C6 radiculopathy. 58 patients (61%) had right sided radicular pain. 5 patients (5.26%) had radiculomyelopathy. C5 – C6 was the most common level operated (68 patients). Excellent results were achieved in 75 patients (79%) while satisfactory results in the rest of patients using Odom’s criteria. Bony fusion occurred in 92% of patients at 6 months. Conclusion:  ACDF with PEEK cage fixation is a safe and beneficial procedure in one level cervical prolapse disc diseas

Early Outcome of Ventriculoperitoneal (VP) Shunt in Terms of Improvement and Complications

Objective:  To analyze the outcome of ventriculoperitoneal (VP) shunts in terms of improvement and complications. Material and Methods:  This retrospective observational study is done in MTI Mardan medical complex and Prime teaching hospital from September 2017 to March 2020. The hospital record of all patients who underwent ventriculoperitoneal shunts was reviewed for improvement and complications. Patients undergoing ventriculoperitoneal shunt for normal pressure hydrocephalus were excluded from this study. Revision of ventriculoperitoneal shunt was the primary endpoint of the study. Results:  A total of 167 patients were operated on for ventriculoperitoneal shunts with males 106 (63.47%) and females 61 (36.52%). Age ranged from 1 month to 75 years with a mean of 14 years. The most common indication for surgery was congenital hydrocephalus in 102 patients (61.1%) while brain tumors caused hydrocephalus in 25 (15%) patients. Common presenting symptoms were the increase in head size in 75 (44.9%), and headaches in 84 (50.2%) patients. Symptomatic (headache, vomiting, and increase in OFC) improvement occurred in 145 patients (86.82%). Shunt revision was needed in 50.29% (84 patients) in one year. Conclusion:  VP shunt is a life-saving procedure and is an effective treatment of hydrocephalus but is not risk-free. Almost half of the shunted patients will need revision surgery in one year period. Keywords:  Hydrocephalus, Ventriculoperitoneal Shunt, Occipitofrontal Circumference (OFC)

Spectrum of Spinal Dysraphism in Pediatric Patients in a Tertiary Care Hospital

Objectives:  To report the spectrum of spinal dysraphism presenting in pediatric patients admitted to the Department of Neurosurgery Lady reading hospital Peshawar. Material & Methods:  A descriptive case series was conducted and total of 89 patients (age between 2 months to 12 years) were included who underwent the surgical treatment. All patients were examined for clinical and radiological diagnosis of spinal dysraphism. Results:  The average age at treatment was 23 ± 39.77 months. The most recurring (52.8%) presenting symptom was the swelling on the back followed by lower limb weakness. Meningocele was reported in 11.2%, myelomeningocele in 47.2%, myelomeningocele & hydrocephalus in 12.4%, tethered cord syndrome in 25.8%, and diastematomyelia 3.4% of patients. Excision combined with the repair was done in 58.4%, release & repair done in 29.2% and endoscopic third ventriculostomy/ventriculoperitoneal shunts with the repair were done in 12.4% patients. Cerebrospinal fluid leak was reported in 3.7%, wound infection in 4.5% and mortality was reported in 3.4% patients. Conclusion:  Overall, a good outcome was reported in the majority of our patients. Surgical procedures like myelomeningocele’s excision & repair, tethered cord’s release & repair, and ETV/VP shunt in patients with hydrocephalus can lead to satisfactory clinical outcomes

Outcome of Surgical Treatment for Lumber Disc Herniation Causing Painful Incomplete Foot-Drop

Objective:  To determine the outcome of surgical treatment for lumder disc herniation causing the painful incomplete foot drop. Material and Methods:  This retrospective observational study was conducted at the Department of Neurosurgery Lady Reading Hospital, Peshawar. Both Male and female patients with lumbar disc disease causing unilateral incomplete painful foot drop were included in our study. Patients with complete or painless foot drop, bilateral foot-drop, Multiple level disc prolapse, cauda equina syndrome or sciatic neuropathy due to injection injury were excluded. Patients were followed was post-operatively in terms of power in foot dorsiflexion, medical research council (MRC) grade and pain relief  on a Visual Analogue Scale (VAS) after 1 month and then after 6 months. Results: Total number of patients included were 43. Age was ranging from 18 years to 54 years and mean age was 33 years. Before surgery,  power of MRC grade 3 or less, but greater than 1 in dorsiflexion was noted in all patients. The pain was scaled using VAS. Post peratively, at 1 month follow up, the foot-drop improved to MRC grade 4 or 5 along with pain relief of ≥ 2 points on VAS in 81. 4% (n = 35) patients and at 6 month follow-up, the figure rose to 93% (n = 40). Conclusion:  Lumbar disc disease can cause a debilitating foot-drop and pain. Improving or restoring a neurology early surgical intervention has proven benefits

Neurological Improvement after Decompression for Dorsal Spine Tuberculosis (TB)

Objectives:  To assess the neurological improvement after decompression for dorsal spine tuberculosis in terms of Frankel grading. Materials and Method:  Prospective study was done in the Neurosurgery department, Prime Teaching Hospital Peshawar from 2018 to 2021. Patients of both genders aged between 18 to 60 years were selected while those unfit for surgery or requiring conservative management were excluded from the study. After clinical examination and radiological findings, the patients were diagnosed with dorsal spine tuberculosis requiring surgery. All patients were followed for 3 months post-operatively. Neurological improvement was measured by comparing pre and post-op Frankel grading. Complications were also documented. Results:  Out of 38 patients included in the study, 16 (42%) were male and 22 (58%) were female. The mean age of presentation was 34 ± 5. The distribution for age groups was 18 – 30 (08), 31 – 40 (13), 41 – 50 (11), and 51 – 60 (06). Level of disease D4 – D8 were 17 (44.8%) and D9 – D12 was 21 (55.2%). Pre-operative neurological status of the patients was (5.2%) Frankel A, (10.5%) Frankel B, (47.3) Frankel C, (22%) Frankel D, and (7.8%) Frankel E while Post-operative grading was (2.6%) Frankel A, (5.2%) Frankel B, (23.6%) Frankel C, (47.3%) Frankel D and (18.4) Frankel E. 3 patients experienced worsening of neurology, 2 patients bleeding and CSF leak and 1 patient died as a complication of the surgery. Conclusion:  Surgical option involving decompression of spine TB followed by stabilization is utilized in a majority of patients with neurological deficits. It is very effective and the results are good. The main advantage is thorough debridement and achievement of spinal stabilization. Keywords:   Dorsal Spine Tuberculosis, Frankel Grading, Spinal Stabilization

Morphophysiological Responses of Oat (Avena sativa L.) Genotypes from Pakistan’s Semiarid Regions to Salt Stress

Soil salinity is a major constraint to modern agriculture, with around 20% of the previously irrigated area becoming salt affected. Identifying suitable salt stress-tolerant genotypes based on their agronomic and physiological traits remains a herculean challenge in forage-type Oat (Avena sativa L.) breeding. The present study was designed to investigate the response of oat crop plants against the salt (NaCl) stress in Mardan, Pakistan. The experiment was carried out in complete randomized design (CRD) with two factors trail comprising of the performance of four different genotypes of oat (NARC oat, PARC oat, Green Gold and Islamabad oat) in response to four levels of saline stress (0, 25, 50 and 75 mmol L-1 NaCl). Plant growth and physiological parameters including germination (G, %); fresh shoot weight (FSW, g); fresh root weight (FRW, g); chlorophyll-a, chlorophyll-b, total chlorophyll, and total carotenoids were analyzed for identifying salt tolerance. Germination (%) of oat genotypes was negatively affected by higher salt stress. Mean values showed that maximum germination (57.5%) was recorded for control while minimum germination (48.75%) was recorded for 25 mmol L-1 NaCl and that maximum germination (58%) was recorded for PARC oat. The root and shoot fresh weight of all genotypes declined with increasing salt stress, while NARC and Green Gold oat showed considerably higher values than the other genotypes. Although chlorophyll and carotenoids were found to be negatively affected by increasing salt concentrations, NARC and Green Gold oat genotypes performed considerably better at 75 mmol L-1 NaCl when compared to the other genotypes. Based on the mean shoot dry weight ratio ± one standard error, the four Oat genotypes were categorized as salt-tolerant (Green Gold), moderately tolerant (PARC and NARC), and salt-sensitive (Islamabad). The more salt-tolerant genotype (Green Gold) demonstrated relatively high salinity tolerance and may be useful for developing high-yielding oat hybrids in future breeding programs under salt stress conditions

Patterns of Motorbike Accidents Related Head Injuries in Patients Presenting to a Tertiary Care Hospital of Peshawar

Objective: To determine the different patterns of motorbike related head injuries in patients presenting to a tertiary care hospital of Peshawar.Materials and Methods: It was a prospective (observational) study, which was conducted at the Neurotrauma ward of Neurosurgery department, Lady Reading Hospital, Peshawar from January 2016 to June 2016. Total number of patients were 246. We included those patients who were having impaired Glasgow Coma Scale (GCS), danger signs and having some abnormal findings on CT brain. We excluded those patients who were having GCS 15/15 and those patients of head injury having associated co-morbid conditions.Results: There were 230 (93.49%) males and 16 (6.5%) females. Age range was 1 to 80 years. Majority of pati-ents were drivers (55.28%). Only 6 (2.43%) drivers used helmet. Ninety patients (36.58%) had an ICU stay of more than one week. Seventy six (30.89%) patients were operated and 170 (69.1%) patients were treated con-servatively. Mortality was 14.63% in our study.Conclusion: Majority were males in our study, most of the patients who sustained head injury in motorbike accidents were drivers. Thirty six percent of the patients needed ICU stay of more than 1 week. Maximum of the patients needed conservative treatment

Spectrum of Different Spinal Disorders Presenting to Neurosurgical Department of Public Sector Tertiary Care Hospitals of Peshawar

Objectives: To assess the spectrum of different spinal disorders presenting to the Neurosurgical department of public sector tertiary care hospitals of Peshawar.Materials and Methods: This was a retrospective study carried out in the Neurosurgery departments of two public sector tertiary care hospitals in district Peshawar from January 2012 to December 2018. Our inclusion criteria comprised of all those patients who were having spinal abnormalities irrespective of age and gender, admitted either via emergency or OPD. We excluded those patients who were dead on arrival or whose data was lacking including those who did not do their follow up and those who were not given consent for the study.Results: Out of total 5,579 patients, male to female ratio was 1:1.7. The age range was from 6 days to 78 years. Elective cases were 63.61% (n = 3,549) and emergency were 36.37% (n = 2,030). TSCI were 35.01% (n = 1,953) and NTSCI were 3,626 (n = 64.99%). Out of all patients, 91.03% (n = 5,079) were treated surgically. About 79% (n = 4,406) had a good outcome.Conclusion: We collected data and made a survey of the spectrum of different spinal abnormalities resulting from various etiologies focused over the last 6 years. We found a variety of cases presenting to our departments of neurosurgery. Non traumatic spinal injuries are more frequent as compared to traumatic ones

SuprasellarArachnoid Cyst as a Cause of Triventricular Hydrocephalus, Found Incidentally During Endoscopic Third Ventriculostomy

Background: Arachniod cyst is a rare congenital disorder of the brain accounting 1% of all intracranial masses. They may also be acquired following head trauma, meningitis, tumors or surgery. They may be the cause of triventricular hydrocephalus (TVH). It occupies the third ventricle so flow of CSF is obstructed at aqueduct of Sylvius. Per operatively, it differs from colloid cyst in consistency, its capsule is transparent and blood vessels are visible. Objectives: To determine the frequency of suprasellar arachnoid cyst as cause of triventricular hydrocephalus and outcome of ventriculocystocisternotomy performed for these cysts at Lady Reading Hospital, Peshawar. Materials and Methods: A retrospective study of 18 cases who undergone ETV for congenital TVH from January, 2013 to December 2015 at Neurosurgery department LRH was performed. On pre operative CT scan brain they were having triventricular hydrocephalus. Ventriculocysto-cisternotomy was performed in all these cases. Biopsy was taken in all cases. Results: Out of these 18 cases, 11 (61%) were males. The presenting symptoms in our study were that infants presented with increased head circumference (n = 3) 16.6%. In pediatric and middle age group the symptoms were those of elevated ICP (n = 13) 72.22%. No endoscopic complication occurred during the procedure except for clinically non-significant bleeds. We followed all cases for a period of 6 months. Clinical and radiological improvement occurred in all cases. Conclusion: Arachnoid cyst should also be considered as a differential for congenital TVH. Endoscopic Ventriculocystocisternotomy is the treatment option of choice forsuprasellararachnoid cyst.  Abbreviations: TVH: Triventricular Hydrocephalus. CSF: Cerebral Scleral Fluid. ICP: Intracranial Pressure. AC: Arachnoid Cyst. SSCs: Suprasellar arachnoid cysts. VC: Ventriculocystostomy. VCC: Ventriculocystocisternotomy. CT: Computer Tomography