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

Improved shear strength prediction model of steel fiber reinforced concrete beams by adopting gene expression programming

In this study, an artificial intelligence tool called gene expression programming (GEP) has been successfully applied to develop an empirical model that can predict the shear strength of steel fiber reinforced concrete beams. The proposed genetic model incorporates all the influencing parameters such as the geometric properties of the beam, the concrete compressive strength, the shear span-to-depth ratio, and the mechanical and material properties of steel fiber. Existing empirical models ignore the tensile strength of steel fibers, which exercise a strong influence on the crack propagation of concrete matrix, thereby affecting the beam shear strength. To overcome this limitation, an improved and robust empirical model is proposed herein that incorporates the fiber tensile strength along with the other influencing factors. For this purpose, an extensive experimental database subjected to four-point loading is constructed comprising results of 488 tests drawn from the literature. The data are divided based on different shapes (hooked or straight fiber) and the tensile strength of steel fiber. The empirical model is developed using this experimental database and statistically compared with previously established empirical equations. This comparison indicates that the proposed model shows significant improvement in predicting the shear strength of steel fiber reinforced concrete beams, thus substantiating the important role of fiber tensile strength.National University of Science and Technolog

Far Lateral Transcondylar Approach for Anterior Foramen Magnum Lesions

Objective:  To study the efficacy and safety of far-lateral transcondylar approach for anterior foramen magnum lesions with early experience at our Institute. Material and Methods:  We treated six patients, with lesion anterior to the foramen magnum and posterior to the brainstem and cervical cord in a period of 2 years, March 2017 to March 2018.Initial assessment was made by history and examination followed by CT scan and contrast MRI. All were treated using far-lateral transcondylar approach. Result:  Among six patients, there were two were male and four were female. Three of these patients had a meningioma while two patients had neurofibromas and one clival chordoma. Total excision was achieved in five neoplastic cases, while subtotal excision was done in one case. There were no fresh postoperative deficits in any of the other patients. One patient had an unexplained sudden cardiorespiratory arrest 18h after the surgery and succumbed. One patient had cerebrospinal fluid (CSF) discharge from the wound, which was satisfactorily managed by lumber CSF drainage. Conclusion:  This approach provides an excellent approach to lesions located anterior to foramen magnum posterior to the brainstem and upper cervical cord. Gross total excision of these benign and malignant lesions is safely possible through this approach. Keywords:  Craniovertebral Junction, Far-Lateral Transcondylar Approach, Anterior Foramen Magnum, Brain Stem, Chordoma

Phytotoxic, Antibacterial and Haemagglutination activities of the aerial parts of Myrsine africana L.

The crude methanolic extract and various fractions derived from the aerial parts of Myrsine africana were screened in vitro for possible phytotoxic, antibacterial and haemagglutination activities. Moderate phytotoxic activity (31.25 %) was observed against Lemna minor L at 1000 μg/ml by chloroform fraction (CHCl3). The crude methanolic extract and CHCl3 fraction showed good antibacterial activity against Klebsiella pneumoniae (MIC50 = 2.45 and 2.1 mg/ml respectively). The crude methanolic extract and other fractions showed moderate activity against tested bacterial strains. The CHCl3 and aqueous fractions showed no activity against Escherichia coli. Similarly, the ethyl acetate (EtOAc) and butanol (BuOH) fractions were found to be non active against Bacillus pumilus and Enterobacter aerogenes, respectively. Moderate haemagglutination activity was observed against human red blood cells (RBCs) of blood group AB- by crude methanolic extract and CHCl3 fraction and against AB+ by aqueous fraction, respectively. The plant specie can be a source of antibacterial agent(s) and phytolectins.Keywords: Myrsine africana, phytotoxicity, haemagglutination, antibacterial and MIC5

Chiari Malformation with and without Syringomyelia: Surgical Technique and Outcome in 88 Adult Patients

Objective:  This study identified the relationship between posterior fossa craniectomy, expansion neuroplasty, and radiological appearances in patients with Chiari malformation with and without clinical syringomyelia with the surgical outcomes in an attempt to correct the lesion. Materials & Methods:  Eighty-eight patients with Chiari malformation (CM) were included in the study where 70 had associated syringomyelia. All underwent posterior fossa craniotomy, expansion duroplasty without fiddling with cerebellar tonsils. Patients were evaluated at 1 month, 3 months, and 12 months. The MRI studies were done at 12 months when symptomatic relief and radiological findings were evaluated and matched. Results:  Most of the patients were young adults between the age range of 25 – 40 years. The most common complication was pseudomeningocele (5.68%) formation followed by CSF leak (4.54%). Patients with a longer history of Chiari malformation or syrinx-related symptoms and signs had partial relief in symptoms and signs. The poor outcome as expected was seen in patients with atrophic changes in upper limbs and hypertonia in lower limbs, especially in patients with loss of joints position sense and poor balance. Patients showed maximum improvement in headaches both suboccipital as well as generalized. Syringomyelia was decreased in size in 49 patients and remained unchanged in 21.  Dysesthesias were improved in 31 patients. Conclusion:  Clinical improvement was related to the expansion of the posterior fossa and subarachnoid cistern and reduction in the size of the syrinx. Surgical decompression of the posterior fossa should create adequate space for its contents and reduce the syrinx cavity. The relationship between symptomatic improvement and radiological findings is not always linear. Keywords:  Chiari Malformation, Tonsillar Herniation, Syringomyelia, Duroplasty

Lipoma at Conus Medullaris without Spinal Dysraphism causing Neurological Deficit: A Rare Occurrence

It's uncommon to have an intradural lipoma without spinal dysraphism. The majority are asymptomatic, however, neurological impairments might occur. For the past six months, a 35-year-old man had been experiencing growing weakening in both lower limbs. The L1 intradural space-occupying lesion was detected during a clinical examination and radiological workup. The patient underwent surgery to address a worsening neurological impairment. The patient had fully recovered neurologically after a six-month follow-up. If the neurological damage is progressive, intradural lipomas should be surgically removed. The surgical treatment produces positive results

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

Microdiscectomy in Relieving Neurological Symptoms in Patients with Lumbar Disc Herniation

Introduction: Minimally invasive spine surgical approaches such as microdiscectomy have gained attention in recent years due to less tissue damage, speedy and acceptable neurological improvement with less complication.Objective: To assess efficacy of microdiscectomy in improving neurological status in patients with lumbar disc herniation.Material and Methods: A Quasi experimental study comprising 70 consecutive cases though non-probability purposive sampling technique of both the sexes admitted in Neurosurgery department, Mayo Hospital operated for the 1st time for any disc pathology with no other spinal lesions giving consent themselves or though legal guardians was conducted. Pain for leg and back was measured pre and post-operatively was done by VAS which had 42 days of follow up. Standard Neurological examinations were conducted pertaining to muscle power (by MRC), sensory status and SLR test pre and post-operatively. Variables according to their nature were expressed in the form of Mean ± SD, Median (Range) and Frequency (percentage). Mc Neumer’s chi square test and paired t test were used to see association between pre-operative and post-operative Neurological status (MRC grade, sensory status, SLR) depending on their nature viz: qualitative or quantitative respectively in SPSS version 15 and hence efficacy of microdiscectomy was assessed.Results: Out of 70 patients 74% were male and 26% were females. Mean ± SD of patients was 37.6 ± 13.0 years. Majority were Laborers after housewives. Illiterates, Poor lifting techniques were the most common characteri-stics in the respective headings of education and employment. Most common level of disc herniation was L4-L5, L5-S1 level (96%) where Prolapse and extrusion were most common MRI findings. As compared to pre-operative (3.4) muscle power 1st and 42nd day power were respectively 4.0 and 4.7 (p = 0.001). Pre-operatively only 32 (45.7%) had normal sensation which improved to 38 (54.3%) and 51 (72.9%) respectively in 1st and 42nd day of surgery (p = 0.001). Pre-operative mean SLR improved to 98.6 degrees in 1st POD and continued to be the same till 42nd day (p = 0.001). All the MRC findings, sensory status and SLR values in each post-operative days were statistically significant with the baseline by paired t test (p = 0.001).Conclusion: Microdiscectomy is one of the effective procedures which can be adopted for symptomatic unilateral lumber disc herniation with significant improvement in Neurological statuses

Predictors of Surgical Outcome Following Cerebral Contusion in Severe Head Injuries

Objective:  There are controversies regarding the management of Cerebral Contusion. The study sought to identify parameters influencing the surgical outcome of individuals suffering from a brain contusion. Methods:  A quasi-experimental study was conducted at the Department of Neurosurgery, Mayo Hospital Lahore, and 37 patients were included. The information on the mode/mechanism of injury, time of presentation, clinical presentation, and contusion type/location was collected. GCS (at 1st, 2nd and 6th weeks) and GOS were used for the neurological assessment of pre-operative and post-operative status. Results:  The average age of presentation was 42.57 years. There were 21.6% female and 78.4% male patients. 64.9% presented with road traffic accidents. 4% of patients presented to the hospital within 12 hours of injury, 16.2% between 12 to 24 hours, and 5.4% between 24 to 48 hours. 29% had seizures and upgoing plantar. 18% had hemiparesis or hemiplegia. Light reflex was absent in 40.5% of patients. The GCS kept improving postoperatively. GCS at admission was averaging 8 which improved to 10, 12, and 13 after surgery. The presenting mean GCS at 1st-week, 2nd-week, 6th-week, and mean GOS at 30th PAD. Counter coup injury improved to 15/15 right in 1st week. Mean GOS was 5 at 30th PAD. The most improvement was seen in the frontoparietal, temporoparietal, and fronto-temporo-parietal locations. The mean GOS at 30th PAD was 4. Conclusion:  The outcome following cerebral contusion depends upon the initial presenting GCS and GOS. Therefore, the better the presenting GCS and GOS better is the prognosis of the patient

Roles of Sociodemographic Characteristics in Determining Neurological Outcomes in Patients with Lumbar Disc Herniation after Microdiscectomy

Introduction: Socio-demographic characteristics like age, gender, occupation has important role in causation of lumbar disc herniation which may even affect their recovery after the surgery. We want to explore the difference in improvement in Neurological status in terms of difference in socio-demographic characteristics of patients.Objective: To find variation in improvement in Neurological status in post microdiscectomy lumbar disc herniation patient stratified in terms of socio-demographic characteristics.Material and Methods: A Quasi experimental study comprising 70 consecutive cases though non-probability purposive sampling technique of both the sexes admitted in Neurosurgery department, Mayo Hospital operated for the 1st time for any disc pathology with no other spinal lesions giving consent themselves or though legal guardians was conducted. Pain for leg and back was measured pre and post-operatively was done by VAS which had 42 days of follow up. Standard Neurological examinations were conducted pertaining to muscle power (by MRC), sensory status and SLR test pre and post-operatively. Variables according to their nature were expressed in the form of Mean ± SD, Median (Range) and Frequency (percentage). Comparisons between categorical and continuous variables were done with the help of t test and one way ANOVA and comparison between both categorical variables was done with the help of chi square test in SPSS version 15.Results: Out of 70 patients 74% were male and 26% were females. Mean ± SD of patients was 37.6 ± 13.0 years. Majority were Laborers after housewives. Illiterates, Poor lifting techniques were the most common charac-teristics in the respective headings of education and employment. Most common level of disc herniation was L4-L5, L5-S1 level (96%) where Prolapse and extrusion were most common MRI findings. Improvement in motor power, sensory status was not dependent on any of socio-demographic characteristics. Improvement on SLR was associated with male genders on 1st (p = 0.03) as well as 7th, 21st and 42nd PODs (p = 0.001).Conclusion: Except gender in SLR value improvement, no other socio-demographic characteristics alter the improvement status in LDH patient after microdiscectomy