Importance of Simpson/Shinshu Grading in Meningioma’s Excision, Outcome and Recurrence

Objective:  The study was aimed to determine the recurrence rate and recurrence-free survival of meningioma surgery with reference to Simpson grading of excision. Material and Methods:  The study was conducted in the Department of Neurosurgery, Punjab Institute of Neurosciences (PINS), Lahore. Total 325 patients both male and female of age (13 – 70 years) with supratentorial grade I meningioma operated. The craniotomy with maximum safe excision of the meningioma was done in all patients under general anesthesia. All patients followed-up to one year clinically and radiologically. MRI brain plain and IV contrast were done at 6 months and then annually. The extent of resection was determined with the help of operative notes and post-op MRI and recurrences were studied with help of follow-up MRI. Results:  There were 227 female and 98 male patients in ages 13 – 70 years. The mean age of patients was 53.5 years. 227 (70%) skull base meningioma, 71 (22.0%) convexity meningioma, and 26 (8%) falx or tentorium meningioma were operated. We achieved Simpson grade I excision in 55 (17.45%), grade II in 208 (64%), grade III in 23 (7%), and grade IV in 36 (11%) cases. The median recurrence free survival (RFS) with reference to Simpson grading of excision was 250, 120, 98, 80 months for grades I, II, III, and IV excision; it was statistically significant according to the grading of excision.  Conclusion:  Excision of meningioma up to grades I and II had an excellent outcome with minimum chances of complications

Endoscopic Discectomy versus Microscopic Discectomy

Objective:  A randomized control trial was conducted to compare the outcome of an endoscopic discectomy with microdiscectomy in lumbar spine disc disease. Material and Methods:  A randomized control trial was conducted at the Department of Neurosurgery, Punjab Institute of Neurosciences (PINS), Lahore. We included 80 patients of ages between 13 – 65 years, with low backache with radiation towards legs and prolapsed intervertebral disc at L5 – S1 and L4 – L5 levels on MRI were included in the study. Endoscopic/microscopic discectomy was done in a randomized manner under general anesthesia in a prone position with fluoro guidance. Postoperatively, all patients stayed in the recovery room for two hours for monitoring and then shifted to the ward. All patients followed-up-to one year clinically with the help of the Oswestry disability index (ODI). Results:  There were 37 female and 43 male patients in the ages between 13 – 65 years. The mean age of patients was 53.5 years. The 53 patients were having prolapsed disc at L5 S1 levels and 27 patients with disc prolapse at L4 – 5 levels. A good improvement was observed in visual analog scores after surgery in both endoscopic and microscopic discectomy groups. But endoscopic discectomy group required a lesser hospital stay, early mobilization, and lesser postoperative analgesia requirements than the microscopic group. Conclusion:  Endoscopic/microdiscectomy both are equally effective and safer techniques. They both can relief. However, the endoscopic discectomy was found better in terms of early mobilization and lesser postoperative pain

Frequency of Elevated Mean Platelet Volume in Patients with Different Severities of Acute Ischemic Stroke

Objective: Determine the frequency of elevated mean platelet volume in patients with different severities of acute ischemic stroke who presented in Lahore general hospital Lahore.Study Design: Cross sectional survey.Duration: Study duration was 1year.Sample Size: 130 patients of acute ischemic stroke.Sample Technique: Non-probability purposive sampling.Methodology: Consecutive 130 patients of acute ischemic stroke presented to emergency department or admitted through OPD within 24 hours of onset of symptoms and fulfilling the inclusion criteria were selected. Patients were divided in two groups based on mRS scoring. MPV was measured by automated hematology analyser Sysmex KX-21. The severity of stroke was assessed by Modified Rankin Score (mRS) between 24 to 72 hours of onset of symptoms.Patients with acute ischemic stroke proved by CT brain presenting within 24 hours of symptom onset and Age 40 and above and both genders were include. Patients with hematological malignancies were excluded from study.Data Collection: 130 patients admitted patients (through emergency and outdoor), Lahore General Hospital, Lahore fulfilling the inclusion criteria were selected for study.The severity of stroke was assessed by modified Rankin Scoring (mRS). The patients were divided in to two groups based on mRS scoring. Mean platelet volume and mRS score were recorded. Major risk factors like hypertension, diabetes mellitus, smoking history and hypercholesterolemia if present were also recorded. The demographic information of these cases like name, age, sex and address recorded. The collected information was entered into SPSS version 11.0. Quantitative variables like age, mean platelet volume were analyzed as mean and standard deviation. Frequencies of elevated MPV in both groups were described. Gender and severity of stroke (mild, moderate to severe) were analysed as frequency and percentage. Elevated MPV was also analysed as frequency and percentage in both groupsResults:  Among the enrolled 130 patients 80 (61.5%) were males and 50 (38.5%) were females (Table 1, Graph 1) with age ranging from 41 – 74 years with a mean age of 56.85 ± 10.15 years. 45 (35%) patients had modified Rankin scale (mRS) between 0 to 2 while 85 (65%) patients had mRS between 3 to 6. Overall mean platelet volume was found to be elevated in 85 patients. Among them 62 (73%) patients had mRS of 3 – 6 (group 2) while 23 patients had mRS of 0 – 2 (group 1). Among the 45 (23%) patients who had normal mean platelet volume, 22 belonged to group 1 (mRS 0 – 2) while 23 were in group 2 (mRS 3 – 6).Conclusion: MPV, with an easy way of measurement, may be anearly and important predictor for the prognosis of ischemic stroke

Anosmia in Parkinson’s Disease in Pakistan: A Matched Case – Control Study

Objective:  To assess olfactory dysfunction in Parkinson's disease (PD) patients in Pakistan utilizing an autochthonous smell test. Setting:  Tertiary care center, single-center study. Materials and Methods:  Eighty-seven non-demented patients with PD, who fulfilled Queen Square Brain Bank Criteria were enrolled at the Movement Disorder Clinic, Lahore General Hospital (LGH), Lahore. Fifty-eight controls matched by gender, age, and place of residence were enrolled among patients and visitors attending other hospital clinics. Both groups underwent olfactory testing using the Pakistani Smell Identification test (PKSIT). The participants were required to identify the smell from a set of choices and were scored out of 10. Results:  Among patients in the study group, the mean duration of disease was 4.7 years (range 6 months to 19 years). The PD onset mean age was 52.15 ± 13.02 years among patients. The mean number of smell test items accurately recognized by the PD patients was 4.55 ± 2.4. A multiple linear regression demonstrated that age (P < 0.05) but not disease duration (P = 0.899) was a significant determinant of the smell test result in PD and control groups. The mean number of smell test items appropriately recognized by the controls was 7.33 ± 1.69. Logistic regression showed that the PKSIT had 73.2% sensitivity and 84.3% specificity to distinguish PD from control. Conclusion:  PKSIT being easily available, cheap, and more convenient to use in the Pakistani population, can be used in the evaluation of olfactory dysfunction in PD subjects

Surgical Outcome of Spontaneous Intracebellar Haemorrhage

Introduction: The management of spontaneous intracerebellar hemorrhage has always been a challenge for neurosurgeons and neurophysicians. So far, neither medical nor surgical intervention has been shown consis-tently to improve the outcome. In this study, we described our experience of surgery for the treatment of sponta-neous cerebellar haemorrhage.Objective: To determine the frequency of good outcome of surgical evacuation of intracerebellar hematoma.Materials and Methods: This was a descriptive prospective study conducted at the department of Neurosurgery PGMI / Lahore General Hospital Lahore. Duration of study was 1 year from 6th August 2010 to 6th August 2011. This study included 75 patients with spontaneous intracerebellar haemorrhage that underwent surgical treatment. Patients were followed for 30 days to see the frequency of good outcome.Results: The mean age of the patients was 60.60, SD 9.43 years (range 43 – 77). There were 15 (20%) patients of age range of 40 – 50 years, 19 (25.3%) patients of age range of 51 – 60 years, 33 (44%) patients of age range of 61 – 70 years, and 08 (10.7%) patients in the age range of 71 – 80 years). There were 51 (68%) male patients and 24 (32 %) female patient in the study. There were 33 (44%) patients who showed good outcome after surgical treatment of spontaneous intracerebellar haemorrhage.Conclusions: Surgery for spontaneous intracerebellar hemorrhage holds good outcome and should be conside-red for intracerebellar hemorrhage

Micro-Endoscopic Discectomy versus Open Discectomy: A Struggle for Better Clinical Outcomes

Objective:  The objective of the current study was to compare the clinical outcomes of a micro-endoscopic discectomy with an open discectomy. Materials & Methods:  This Quasi-experimental study was conducted in the Department of Neurosurgery, Alrazi Healthcare, Lahore, and Ammar Medical Complex, Lahore. The sample consisted of 40 patients with lower back pain with radiation to the lower limbs. A lumbar disc single-segment hernia was diagnosed based on magnetic resonance imaging (MRI) findings. Independent sample t-test was used to explore the difference in outcomes and level of pain between group A and group B. Chi-square test was used to compare the recovery rate of patients in both groups. Results:  A significant difference between the two groups in terms of surgery duration (t = 15.977, P = .000), blood loss during surgery (t = -10.256, P = .000), length of incision (t = -58.355, P = .000), and hospital stay after surgery (t = -4.687, P = .000) was found. The overall recovery rate for the micro-endoscopic Discectomy group was 95% whereas, in the open discectomy group, it was 90%. Conclusion:  Micro-endoscopic discectomy is superior to open discectomy in terms of lesser surgical trauma, lesser blood loss, lesser hospital stay, earlier return to work, and higher pain resolution

Surgical Outcome of Cerebellopontine Angle Tumours by Retrosigmoid Approach

Objective: To determine the microsurgical outcome of cerebellopontine angle tumours by the retrosigmoid approach. Study Design: Quasi experimental study. Place and Duration of Study: Departments of Neurosurgery Lahore General Hospital and mayo hospital, Lahore from January 1998 to June 2015. Materials and Methods: Four hundred and fifty six patients of cerebellopontine angle tumours of various histologies were operated at the Departments of Neurosurgery, Lahore General Hospital and mayo hospital, Lahore, from Jan 1998 to June 2015. All patients with unilateral or bilateral lesions from 15 to 65 yrs of age and with all different pathologies in cerebellopontine angle were included in the study. Complete blood count, X-Ray Chest and MRI Brain plain and with I.V contrast were done. Patients with pre-operative radiosurgery, multiple surgeries and those unfit for surgery were excluded from the study. All patients were operated under general anaesthesia by retrosigmoid approach in park bench position. Preservation of the facial nerve was attempted in all cases. Post op facial nerve status was compared with pre-op grade by House – Brackman grading. Post op development of hydrocephalus and other cranial nerve complications were also noted and overall morbidity and mortality was studied.Results: Four hundred and fifty six patients, 274 men (60.1%) and 182 women (39.9%), underwent micro-surgical excision of cerebellopontine angle tumours. 410 (89.9%) patients were vestibular schwannomas,22 (4.8%) were meningioma, 9 (1.9%) were epidermoid and 13 (2.8%) were all other pathologies in cerebello-pontine angle tumours. Patient ages ranged from 15 to 65 years (mean 44.11±8.41 years). All patients were operated by the Retrosigmoid approach. Complete resection was achieved in 237 patients (51.9%), subtotal resection (STR) in 209 patients (45.8%), and near-total resection (NTR) in 10 patients (2.1%). Good facial nerve outcomes (House-Brackmann [HB] Grades I-III) were achieved in 82% of the patients who had undergone either NTR or STR, as compared with 73% of patients who had undergone gross-total resection (GTR). Complications included wound infection (2 patients), delayed CSF leakage 10 (2.1% of patients), hydrocephalus requiring VP shunt in 15 (3.2%), basal cranial nerve palsy in 45 patients (9.8%) and mortality in 10 (2.1%). Conclusion: Retrosigmoid approach is relatively easy and safe approach for cerebellopontine angle tumour. Tumours of all sizes can be operated completely and facial nerve can be identified and saved with this approach with less operative time and less chances of CSF leak

Autologous Bone Graft vs PEEK Cage in Patients with Cervical Spondylotic Myelopathy

Background:  Cervical spine stenosis is one of the most common degenerative changes of cervical spondylotic myelopathy (CSM) and results in severe dysfunction of the cervical spinal cord. The conventional treatment of such degenerative cervical spine conditions is anterior cervical discectomy and fusion (ACDF). Strut graft remains the gold standard in ACDF with excellent patient recovery but has many shortcomings. Polyetheretherketone (PEEK) cages have recently become popular as a replacement for strut grafts in patients undergoing ACDF. Objective:  This study was carried out to compare the clinical and radiographic outcomes of autologous bone grafts versus PEEK cages in patients undergoing ACDF surgery. Materials and Methods:  It was a randomized controlled trial conducted at the Neurosurgery Department Punjab Institute of Neurosciences for three years. Patients who consented to be a part of this study and fulfilled our predefined inclusion criteria were recruited and randomized into 2 groups. One group underwent ACDF with auto bone graft whereas the other group underwent ACDF with PEEK cage. Results:  A total of 198 subjects were included in this study. The mean age was calculated as 47.60 ± 9.17 years in the PEEK cage group and 46.74 ± 8.87 years in the Autologous bone graft group. Males accounted for 59.6% of the study population.  The fusion rate was found to be higher in the PEEK cage group with a p-value of 0.002. Conclusion:  PEEK cages are superior to strut grafts as they have lesser morbidity after ACDF surgery in patients with CSM. &nbsp

Surgical Outcome of Anterior Decompression, Grafting and Fixation in Dorsolumbar Caries Spine

To evaluate the surgical outcome of anterior decompression, grafting and fixation in tuberculosis of the dorsal and lumbar spine.Study Design: Retrospective study.Place and Duration of Study: Department of Neurosurgery Unit – I, Lahore General Hospital, Lahore, From Jan 2008 to March 2012.Materials and Methods: Patients with caries spine having compression over the thecal sac with neurological deficit and kyphosis were included in the study. Patients below 17 years and above 56 year of age; patients with bed sores and unfit patients for anesthesia were excluded from the study. Complete blood picture with ESR, X-ray Chest, X-ray of the relevant spinal level and MRI were done. All patients were treated with corpectomy, debri-dement, drainage of abscess and grafting followed by fixation with poly-axial screws and rods. All patients were assessed by ASIA Impairment Scale before and after surgery and with Bridwell grading after surgery.Results: Among 79 patients, 47(59.49%) Male and 32(40.51%) Female patients, mean age was 37.2 ± 3 years. The commonest involved level was the dorsolumbar junction 53.16% (N = 42). Backache, sensory motor deficit and deformity were main presenting complains. Anterior decompression and grafting followed by fixation with poly axial screw and rods were done in all patients who fulfill the inclusion criteria. Lower limb power improved to ambulatory level in 60% of patients with complete paraplegia and recovery was excellent in patients with partial weakness; only n = 2 patients (2.53%) deteriorated to a lower grade. There was no postoperative mor-tality and one patient had long ICU stay due to lung injury. All patients have pain at the intercostal area and graft donor site that were treated with analgesia.Conclusion: According to our study, corpectomy followed by grafting and fixation is safe and effective pro-cedure. Even those patients presenting with complete paraplegia showed improvement in motor power to ambu-latory level and those who had partial deficit showed excellent improvement

Neurological Outcome of Carpal Tunnel Decompression in Carpal Tunnel Syndrome

Objective: To evaluate the outcome of carpal tunnel decompression in Carpal tunnel syndrome. Study Design: Prospective and retrospective observational study. Materials and Methods: This study was conducted at the Department of Neurosurgery, PGMI / AMC / Lahore General Hospital, Lahore, during the period of 4 years from Jan. 2009 to Jan. 2013. All patients with symptoms and signs of carpal tunnel syndrome and with positive nerve conduction study were included in our study. Exclusion criteria was those unfit for surgery such as patients on warfarin and patient with mild symptoms treated with wrist splint and oral analgesic, diabetic, hypothyroid patient, patients in which nerve conduction study points to radiculopathy and patients with history of trauma with carpal bone fracture were excluded from study. Prospective clinical data collected included patient reported outcome measures and satisfaction scores, touch threshold, pinch and grip strength. Patients were assessed clinically, underwent nerve conduction studies and surgery as indicated. Baseline and one – year follow-up data were analysed for 57 patients (62 hands). Results: A total of 57 patients (62 hands) treated with surgery between Jan 2009 and Jan 2013 agreed to participate in the study. Complete data at baseline and 1 year were available for 57 patients (62 hands). There was significant improvement in all domains of the Boston Carpal Tunnel and Michigan Hand Outcomes questionnaires, grip strength and touch threshold. There were no adverse events. Eight patients (14%) requested advice on scar management or had queries regarding the duration of post-operative recovery of sensation and function. The total mean operating time was 12.8 minutes (range: 5–15 minutes) and the mean tourniquet time was 2.5 minutes (range: 1–11 minutes). Patient satisfaction as judged using a Picker questionnaire was very high. Conclusions: A highly efficient clinical service involving both diagnostics and treatment can be delivered through minimum hospital visit and day care surgery while maintaining optimal outcomes and high patient satisfaction