Steroid Induced Gastrointestinal Perforation in a Traumatic Injury. Atypical Complication to a Common Drug

We report this case of a male patient with cervical spine injury following shallow water diving. With power of 3/5 in all 4 limbs and grade 2 subluxation (C5/C6) the patient was operated on undergoing a 360 degree fixation and unlocking of facets; he was administered steroids and developed abdominal distention. An eventual CT scan showing a pneumoperitoneum revealed he had developed a gastrointestinal perforation. GI perforation is a less well recognized side effect of steroids. It can be difficult to diagnose, as the steroids can mask the symptoms of gut perforation by reducing the clinical expression of peritonitis, and a serious complication; been reported in the literature to have a mortality ranging from 27% to a 100%.1-3 We report this case as a clinical reminder of the risk of GI perforation from steroid use and to emphasize the role of a multi-disciplinary team in the management of trauma patients

11 Years Old Female with Synergistic Presentation of Cranial and Spinal Pathologies: Myxopapillary Ependymoma with Hydrocephalus - A Rare Entity

The correlation between hydrocephalus and spinal cord tumor was first described by Kyrieleis et. al. 1% concomitant presence was documented by Mirroni et.al. Moreover, the understanding of the pathophysiological association between these two conditions is still lacking. 11 years old girl presented in the outpatient department of Jinnah hospital Lahore with complaints of difficulty in walking for the last 2 years, numbness of right leg for the last one year, and severe bilateral sciatica for 2 months. On further inquiry, she told that she is also suffering from headaches and blurred vision for the last 6 months. Her neuroimaging revealed hydrocephalus and mixed density heterogeneously enhancing intradural lesion at the conus. She underwent ventriculoperitoneal shunting for hydrocephalus and laminoplasty followed by excision of spinal tumor reported being myxopapillary ependymoma grade II. The presence of headache along with signs & symptoms of raised intracranial pressure in these patients warrant cranial imaging. CSF diversion for hydrocephalus and gross total excision of the spinal lesion is the standard acceptable treatment

Outcome of Adolescent Bike Riders after Road Crash with and without Safety Measures in a Developing Country

Background: Road traffic crash is of growing public health importance worldwide contributing significantly to the global disease burden. There is paucity of published data on road traffic crashes in our local circumstances. This study was carried out to describe the outcome in patients of traumatic brain injury after road traffic crash in our local setting and provide baseline data for establishment of preventive strategies for the well being of adolescent bike riders.Methods: This was a prospective hospital based study of road traffic crash victims carried out at Department of Neurosurgery, Jinnah hospital Lahore from January 2015 to December 2015. After informed consent from patients or their attendants, all patients were consecutively enrolled into the study. A total of 1490 patients were enrolled in the study who presented in emergency after road crash and only the bike riders were observed for the outcome. Data was collected using a pre-tested questionnaire and analyzed using SPSS computer software version 15.0.Results: A total of 1490 road traffic crash victims were studied. All patients were male. The patients ages ranged from 12 to 57 years with the mean and median of 22.5 and 26 years respectively. The patients were divided into five groups as GROUP-A 10-20yrs age, GROUP -B 21-30yrs, GROUP -C 31-40 yrs, GROUP-D 41-50yrs and GROUP-E 51-60yrs. Regarding the vehicle only bike was included. Number of patients in group A was 340 (22.8%), group B 650 (43.6), group C 80 (5.3), group D 320 (21.4%) and group E 100 (6.7%). Regarding the mechanism 618 (41.4%) patients came after bike skidding, 636 (42.6%) patients came after bike with bike crash and 236 (15.8%) patients came after bike with other vehicle crash. Among total number of patients 216 (14.4%) were those having severe traumatic brain injury (STBI). Mortality rate among STBI was 106 (49.07%). The highest mortality was noticed in group C was 37.7% and in group A(adolescent patients) was 24.5% and this was significant (P < 0.001) whereas regarding the outcome according to Glasgow outcome scale, Grade 5 was observed in 63.6% and Grade 4 & 3 in 13.02% & 14.4% respectively and Grade 2 in 1.7% of the patients. The stratification of patients was also done regarding the severity of injury and their outcome according to GOS. It showed that in group A 22.03% patients with mild TBI had GOS 5 & 6.78% with moderate TBI had GOS 5. Regarding severe TBI of group A 15.38% patients had GOS 2 & 24.53% had GOS 1 which was highest in all groups, same stratification was done for other groups as well which showed that the outcome in group A is devastating and its results are comparable with the elder age groups.Conclusion: Road traffic crashes constitute a major public health problem in our setting and contribute significantly to unacceptably high morbidity and mortality especially for youth. Urgent preventive measures in the form of helmet wearing for bike riders and enforcement of traffic rules targeting at reducing the occurrence of road traffic crashes is necessary to reduce the morbidity and mortality resulting from these injuries. There should be uniform implementation of traffic rules and regulation of motorcycle industry all over the country

Outcome of Partial Application of Non-operative Tools in Management of Severe Traumatic Brain Injury in a Developing Country

Objective: To see the outcome of partial application of non-operative tools like endotracheal intubation and early enteral nutrition on mortality in severe traumatic brain injury. Introduction: Severe Traumatic Brain Injury (TBI) is the leading cause of death in children and young adults1. Mainstay in management of severe head injury is based on the concept that little can be done about primary brain injury but a lot can be done to minimize secondary brain injury because its severity and duration influences the outcome. Several non operative tools can prevent this secondary brain injury and can improve outcome but from these tools only some can be applied in developing countries. These are Endotracheal Intubation, Ventilatory Support, Sedation & Paralysis, Analgesia, Normothermia, Normovolemia, Electrolyte Balance, Enteral Nutrition, Head Elevation and Mannitol

Leukocytosis: Predictor of Radiological and Neurological Outcome of Patients of Traumatic Brain Injury Presented to Jinnah Hospital, Lahore

Background/Objective: Catecholamines and cortisol cause raised TLC (total leukocyte count) and brain inflammation after injury. We found out that weather leukocytosis is predictive for radiological and neurological outcome in patientswith TBI presenting to JHL.Materials and Methods: Blood samples of patients (n = 100) were collected on presentation in the emergency room, after 72 hours and on the 5th day for TLC count.CT Brain was obtained on presentation in emergency, after 72 hours and on the 5th day. The progression of imaging findings on CT scan were assessed and compared with TLC count. The outcome of these patients was assessed according to the Extended Glasgow Outcome Scale.Results: TLC after TBI is raised initially and then it declined afterwards in mild and moderate TBI, but remained on the upper limit in moderate TBI. In severe TBI, TLC was raised initially and then it progressed to higher limits afterwards.These results showed that there is a strong relation between TLC and TBI.Regarding the association between radiological assessment and severity of injury along with raised TLC, it was observed that the patients having EDH had raised TLC along with expansion of hematoma, while patients with contusions, T-SAH (traumatic sub-dural hematoma) SDH had TLC on upper limit, but there was no significant resolution of radiological severityConclusion: WBC count can be used as a predictor of radiological outcome, as it was found that patients with severe head injury had raised TLC. TLC count can be used to assess the severity of injury and prognosis

Virtual Reality in Neurosurgery- A Neurostimulator – Based Postgraduate Residency Training: A Novel Step Towards Skillful Young Neurosurgeons

Introduction/Objective:  Virtual Reality (VR) is the need of time in every field of life. Recent biotechnological advances have molded the surgeon-computer relationship. Department of Neurosurgery Jinnah Hospital Lahore has updated the postgraduate training program by adding the virtual reality simulator. We aim to explore the current and future roles and applications of VR and simulation in neurosurgical training that may reduce the learning curve, improve conceptual understanding and enhance visuospatial skills. Materials & Methods:  Eight residents were enrolled in this program. They exercised the basic skills of neurosurgery e.g. suction, use of bipolar cautery, handling of CUSA, use of micro scissors, etc., and the automated software recorded each participant’s graph of performance separately. After 1.5 years, they were assessed in real-time on actual patients under the direct supervision of a qualified neurosurgeon. The assessment was done on DOPS (Directly Observed Procedural Skills) Performa. Results:  The results showed that there was a gradual upward learning curve in simulator-based procedures from negative marking to 70% in basic surgical skills and 60% in advanced procedures on average for all the residents whereas the DOPS showed that all residents performed above expectation i.e., 4 or above. Conclusion:  Neurostimulator-based postgraduate training program is opening new horizons for the safe and skillful training of residents. With the advancement of artificial intelligence, its use in training programs will lead to structured and systematic training patterns in the world of neurosurgery

Delay in Diagnosis of Brain Tumors: A Dilemma For Neurosurgical Community Due To Spirituality and Quackery In A Developing Country

Objectives:  Primary and metastatic brain tumors are a significant cause of mortality and morbidity. The complex pathway to a cancer diagnosis is not human error and the achievements of better outcomes solely depend on the early diagnosis and management of symptomatic tumors. The estimated time between the first presentation to any health care professional and diagnosis is approximately 3 times longer in the UK as compared to other developed countries. Material and Methods:  It was a descriptive study and included 52 patients who were admitted to the Neurosurgery department at Jinnah hospital Lahore. The required data were collected either directly from the patients or from the hospital record of discharged patients. Our study compares the time interval difference of presentation of a patient to a local care provider (Quacks, Hakeem, and spiritual healers) and Neurosurgeon as well as delay in surgical intervention even after diagnosis and radiological investigations. Results:  54% of patients presented with supratentorial lesions and out of these, parietal lobe lesions were more common (39%) while 29% of lesions were infratentorial. Around 50% of patients presented to a Local Care Provider within 20 days. However, only 42% of patients presented to a neurosurgeon after 6-9 months of the onset of symptoms. Conclusion:  Public awareness is the key to timely diagnosis, proper management, and better outcomes. The availability of specialists in peripheral hospitals can bring a change in this regard

Role of intraoperative computed tomography scanner in modern neurosurgery – An early experience

Background: Intraoperative imaging addresses the limitations of frameless neuronavigation systems by providing real-time image updates. With the advent of new multidetector intraoperative computed tomography (CT), soft tissue can be visualized far better than before. We report the early departmental experience of our intraoperative CT scanner’s use in a wide range of technically challenging neurosurgical cases. Methods: We retrospectively analyzed the data of all patients in whom intraoperative CT scanner was utilized. Out of 31 patients, 24 (77.4%) were cranial and 8 (22.6%) spinal cases. There were 13 male (41.9%) and 18 (58.1%) female patients, age ranged from 1 to 83 years with a mean age of 34.29 years ±17.54 years. Seven patients underwent spinal surgery, 2 cases were of orbital tumors, and 16 intra-axial brain tumors, including 5 low- grade gliomas, 10 high-grade gliomas, and 1 colloid cyst. There were four sellar lesions and two multiloculated hydrocephalus. Results: The intraoperative CT scan guided us to correct screw placement and was crucial in managing four complex spinal instabilities. In intracranial lesions, 59% of cases were benefitted due to intraoperative CT scan. It helped in the precise placement of ventricular catheter in multiloculated hydrocephalus and external ventricular drain for a third ventricular colloid cyst. Conclusion: Intraoperative CT scan is safe and logistically and financially advantageous. It provides versatile benefits allowing for safe and maximal surgery, requiring minimum changes to an existing neurosurgical setup. Intraoperative CT scan provides clinical benefit in technically difficult cases and has a smooth workflow

Evaluation of Midline Shift and GCS as an Outcome in Severe Traumatic Brain Injury

Objectives: We determined the frequency of mortality in patients with traumatic brain injury and to compare frequency of midline shift and poor motor response in traumatic brain injury patients with and without mortality.Materials & Methods: Total 108 patients with severe TBI aged between 18 to 60 years were included. Admission GCS and motor response of post-nonsurgical resuscitation were recorded, along with midline shift on initial CT-scan. All patients were followed for the mortality up to 2 weeks. Chi square test applied for the frequency comparisons of ‘midline shift’ and ‘poor motor response’.Results: Mean age was 38.88 ± 8.94 years. Out of the 108 patients, 68 (62.96%) were males and 40 (37.04%) were females. Mean admission GCS was 3.39 ± 1.87. Mean motor response was 3.12 ± 1.68. Mean midline shift was 7.37 ± 2.09 mm. Mortality was found in 66 (61.11%) patients, whereas, there was no mortality in 42 (38.89%) patients. High mortality percentage (60%) was found in age group: 20-30 years. In male patients, high mortality percentage was found (63.24%) as compared to female patients. Comparable differences were found in the frequencies of ‘midline shifts’ and ‘poor motor response’ in patients with mortality.Conclusion: The frequency of mortality in patients with severe TBI was found high. The ‘motor scores’ and ‘midline shifts’ can predict the outcome of severe TBI, because, comparable differences were found in the frequencies of ‘midline shifts’ and ‘poor motor response’

Prognostic Factors for Decompressive Hemicraniectomy in Severe Traumatic Brain Injury Patients with Traumatic Mass Lesions: A Prospective Experience from a Developing Country

Objective:  To evaluate the prognostic factors affecting functional clinical outcomes in severe traumatic brain injury patients with traumatic mass lesions undergoing decompressive hemicraniectomy (DHC). Materials and Methods:  A prospective cohort of 85 patients of severe traumatic brain injury patients with traumatic mass lesions underwent a unilateral decompressive hemicraniectomy. Functional outcomes were assessed using the Glasgow Outcome Score at 28 days, 3 months, and 6 months. Bivariate analysis (chi-squared) was used to identify parameters that resulted in poor outcomes and multiple regression was used to identify independent factors predicting poor outcomes. Results:  85 patients were recruited. Functional outcomes were dichotomised as favourable (Glasgow Outcome Score of 4 – 5) and poor (Glasgow Outcome Score 1-3) and evaluated at 28 days, 3 and 6 months. A total of 59 patients expired (69.4%). Bivariate analysis revealed GCS 3 – 5 at presentation (P = 0.002), midline shift greater than 7.5mm (P < 0.001), the volume of the mass lesion more than 40ml (P = 0.006) resulted in a poor outcome. Age dichotomised to less than or more than 50 years bordered statistical significance (P = 0.063). Only GCS at presentation and midline shift were independent factors that predicted poor outcomes when controlling for covariates.  Conclusion:  Decompressive hemicraniectomy can be a lifesaving intervention in managing severe traumatic brain injury patients with traumatic mass lesions. However, its use needs to be employed judiciously.&nbsp