Computed tomography-guided biopsy for potts disease: An institutional experience from an endemic developing country

Study design: A retrospective chart review.Purpose: In endemic resource poor countries like Pakistan, most patients are diagnosed and treated for Potts disease on clinical and radiological grounds without a routine biopsy. The purpose of this study was to evaluate the use and effect of computed tomography (CT)-guided biopsy in the management of Potts disease since the technique is becoming increasingly available.Overview of literature: CT-guided biopsy of spinal lesions is routinely performed. Literature on the utility of the technique in endemic resource poor countries is little.Methods: This study was conducted at the Neurosurgery section of Aga Khan University Hospital Karachi. All the patients with suspected Potts disease who underwent CT-guided biopsy during the 7 year period from 2007 to 2013 were included in this study. Details of the procedure, histopathology and microbiology were recorded.Results: One hundred and seventy-eight patients were treated for suspected Potts disease during the study period. CT-guided biopsies of the spinal lesions were performed in 91 patients (51.12%). Of the 91 procedures, 22 (24.2%) were inconclusive because of inadequate sample (10), normal tissue (6) or reactive tissue (6). Sixty-nine biopsies were positive (75.8%). Granulomatous inflammation was seen in 58 patients (84.05%), positive acid-fast bacillus (AFB) smear in 4 (5.7%) and positive AFB culture in 12 patients (17.3%). All 91 cases in which CT-guided biopsy was performed responded positively to antituberculosis therapy (ATT).Conclusions: 75.8% of the specimens yielded positive diagnoses. Granulomatous inflammation on histopathology was the commonest diagnostic feature. In this series, the rates of positive AFB smear and culture were low compared to previous literature

Variation in Outcome in Tethered Cord Syndrome

Study DesignFifty patients surgically treated for tethered cord syndrome (TCS) were retrospectively studied at Liaquat National Hospital, Karachi from 2010 until 2014.PurposeTo assess the common presentations of TCS in our part of the world and the surgical outcome of the different presentations.Overview of LiteratureTCS is a stretch-induced functional disorder of the spinal cord with its caudal part anchored by an inelastic structure, which results in characteristic symptoms and signs. Due to the variety of lesions and clinical presentations and the absence of high-quality clinical outcome data, the decision regarding treatment is difficult.MethodsFifty consecutive patients with TCS were reviewed retrospectively with a follow-up period of 12–48 months. The majority of the patients were 0-15 years of age with the mean age of 4 years. The presenting complaints and the associated pathologies were documented, and the patients were assessed using the new Karachi TCS severity scale for clinical assessment.ResultsEighty five percent of the patients with thickened filum terminale improved. Sixty six percent of the patients with diastematomyelia, 60% with lipoma and only 46% with myelomeningocele showed clinical improvement postoperatively. Sixty two percent of the patients who presented with paraperesis improved following surgery while 37% remained stable and only one patient deteriorated. Back and leg pain improved in 93% of patients and 50% of patients with urinary impairment improved.ConclusionsOutcome of patients with TCS varies according to pathology and severity of symptoms. Diastematomyelia and thickened filum had the best outcome. The Karachi TCS severity scale is a valid tool for future studies

Preventive gabapentin versus pregabalin to decrease postoperative pain after lumbar microdiscectomy: A randomized controlled trial

Study design: Randomized controlled trial.Purpose: The purpose of this study was to compare pregabalin and gabapentin for mean postoperative visual analog score (VAS) for pain in patients undergoing single-level lumbar microdiscectomy for intervertebral disc prolapse at a tertiary care hospital.Overview of literature: Pregabalin has a superior pharmacokinetic profile and analgesic effect at lower doses than gabapentin; however, analgesic efficacy must be established during the perioperative period after lumbar spine surgery.Methods: This randomized controlled trial was carried out at our institute from February to October 2011 on 78 patients, with 39 participants in each study group. Patients undergoing lumbar microdiscectomy were randomized to group A (gabapentin) or group B (pregabalin) and started on trial medicines one week before surgery. The VAS for pain was recorded at 24 hours and one week postoperatively.Results: Both groups had similar baseline variables, with mean ages of 42 and 39 years in groups A and B, respectively, and a majority of male patients in each group. The mean VAS values for pain at 24 hours for gabapentin vs. pregabalin were comparable (1.97±0.84 vs. 1.6±0.87, respectively; p=0.087) as were the results at one week after surgery (0.27±0.45 vs. 0.3±0.46, respectively; p=0.79). None of the patients required additional analgesia postoperatively. After adjusting for age and sex, the VAS value for group B patients was 0.028 points lower than for group A patients, but this difference was not statistically significant (p=0.817, R2=0.018).Conclusions: Pregabalin is equivalent to gabapentin for the relief of postoperative pain at a lower dose in patients undergoing lumbar microdiscectomy. Therefore, other factors, such as dose, frequency, cost, pharmacokinetics, and side effects of these medicines, should be taken into account whenever it is prescribed

Safety of untreated autologous cranioplasty after extracorporeal storage at -26 degrees celsius

Background: Given the improved survival of patients requiring decompressive craniectomies, the frequency of subsequent cranioplasties are on the rise. The most feared complication of autologous cranioplasty is infection and one method for reducing the rate of infection, is to store the bone flaps at subnormal temperatures. However, to date there is no defined temperature for flap storage and temperature ranges from - 18 to - 83°C have been described in literature. Considering our limited resources it has been the practice at our center to store bone flaps at - 26°C. In this study, we have retrospectively reviewed our practice and have audited this choice of temperature with respect to the frequency of infections.Methods: A retrospective review was conducted for all cranioplasties performed at our center between January 2001 to March 2011, using autologous bone which was cryopreserved according to institutional protocol. During this period the operative and cryopreservation protocol remained the same. All patient records including charts, notes and laboratory findings were reviewed with a specific focus to identify infections.Results: Of the 88 patients included in the study, only 3 (3.40%) patients were found to show signs of infection. Of these, two patients had superficial surgical site infections which resolved with oral antibiotics (Co-Amoxiclav 1 gm BD for 7 days). However the third patient developed deep surgical site infection requiring re-exploration and washout. All three patients had complete resolution of infection with preservation of autologous bone.Conclusion: Despite our method of keeping the bone flap in freezer at - 26°C we have reported an acceptable rate of infection and raised the notion whether there is a justification for sophisticated and costly equipment for bone flap preservation, especially in resource depleted setups

Does Trauma Have a Major Role in Ossified Posterior Longitudinal Ligament and Should We Perform Fusion in Every Case?

WOS: 000366286300009PubMed ID: 2614582

Exploring the relationship between rotterdam computed tomography score and surgical outcomes of traumatic brain injury

Background: Data on the evaluation of The Rotterdam Computed Tomography Score (RCTS) as a predictor of outcomes in patients undergoing decompressive craniectomy (DC) for trauma is limited and lacks clarity. Objective: To explore the role of RCTS in predicting unfavorable outcomes, including mortality in patients undergoing DC for head trauma. Methods: This was an observational cohort study conducted from January I, 2009 to March 31, 2013. CT scans of adults with head trauma prior to emergency DC were scored according to RCTS. A receiver operating characteristic curve analysis was performed to identify the optimal cutoff RCTS for predicting unfavorable outcomes [Glasgow outcome scale (GOS) =1-3]. Binary logistic regression analysis was performed to evaluate the relationship between RCTS and unfavorable outcomes including mortality. Results: 197 patients (mean age: 31.4 ± 18.7 years) were included in the study. Mean GCS at presentation was 8.1 ± 3.6. RCTS was negatively correlated with GOS (r = -0.370, p \u3c 0.001). The area under the curve was 0.687 (95 % CI 0.595- 0.779, p \u3c 0.001,) and 0.666 (and 95 % CI 0.589 – 0.742; p \u3c 0.001) for mortality and unfavorable outcomes, respectively. RCTS independently predicted both mortality (adjusted odds ratio for RCTS \u3e3 compared with RCTS ≤ 3: 2.792, 95% CI 1.235-6.311) and other unfavorable outcomes (adjusted odds ratio for RCTS \u3e3 compared with RCTS ≤ 3: 2.063, 95% CI 1.056-4.031). Conclusion: RCTS is an independent predictor of unfavorable outcomes and mortality among patients undergoing emergency DC. Keywords: Rotterdam score, Traumatic Brain Injury, Decompressive Crniectomy, Unfavorable outcome

Emergency department predictors of tracheostomy in patients with isolated traumatic brain injury requiring emergency cranial decompression

Object: Patients with severe traumatic brain injury (TBI) frequently require a tracheostomy for prolonged mechanical ventilation and/or pulmonary toilet. It is now proven that the earlier the procedure is done, the more beneficial it is to the patient. The present study was carried out to determine if the requirement of a tracheostomy can be predicted on arrival of a patient to the emergency department. The prediction can potentially aid in combining the procedure with cranial decompression. In this study, the authors\u27 aim was to determine the emergency department predictors of tracheostomy in patients with isolated TBI requiring emergency cranial decompression.Methods: The authors performed a retrospective chart review of all patients who underwent surgery for isolated TBI and required more than 4 days of mechanical ventilation. Multivariate logistic regression analysis was used for predictive indicators.Results: In patients with isolated severe TBI, a patient age of 31-50 years, the presence of preexisting medical comorbid conditions, a delay in emergency department arrival exceeding 1.5 hours, an abnormal pupil response on arrival, and a preoperative neurological worsening during hospital stay were independent predictors of the requirement for tracheostomy. These findings were validated in a small cohort of patients and were found to be significant.Conclusions: Requirement of a tracheostomy can be predicted in patients with severe TBI on arrival to the emergency department. These results were validated in a small cohort of patients, and it was found that the positive predictive value of requirement of tracheostomy was directly proportional to the number of predictors present. Larger prospective studies with appropriate control groups are further recommended to validate the authors\u27 findings