Trigeminal nerve compression technique for the treatment of trigeminal neuralgia: study of 80 cases in 10 years

Objective: To dtermine the outcome of trigeminal nerve compression technique [TGNC] treatment for the idiopathic trigeminal neuralgia without decompressing the nerve compressed by the offending vessel

Methodology: This case series study was conducted in Hayatabad medical complex, Lady ready hospital and Abaseen hospital, Peshawar from June 2004 to June 2014. Consent from the ethical committee and patients were taken. All patients of idiopathic trigeminal neuralgia [TGN] were included. Those TGN cases having mass lesion were excluded. All information were put in proforma. Results were analyzed by SPSS version 20 and presented in the form of tables

Results: Total number of patients included in the study were 80 in which males were 45 [56.25%] and females were 35 [43.75%]. Male to female ratio of 1.3:1 The ages ranged from 30 to 70 years and mean age was 50 +/-20. Detail history and clinical examination were performed. Routine investigations of complete blood count, HBsAg, HCV and brain MRI were done in all cases. Follow up ranged from 1 to 10 years. Outcome was 77[96.2%] patients were completely pain free while 3[3.8%] of patients developed recurrence. One patient [1.25%] developed CSF rhinorrhea, otorrhea, facial nerve paresis and deafness each

Conclusion: The compression of TN by vascular loop was not found as a cause of TGN. TGNC Technique for TGN is less invasive, safe and effective

Endoscopic third ventriculostomy [ETV]; outcome

To know the surgical outcome of endoscopic third ventriculostomy [ETV] in non communicating hydrocephalous. This study was conducted in Abaseen Hospital, Peshawar, from 13th December 2010 to 12th October 2011. Patients with non-communicating hydrocephalous, irrespective of gender discrimination were included in this study. Patients with communicated hydrocephalous, patients below two years of age and hydrocephalus with infected CSF or hemorrhage were excluded. Hydrocephalous was diagnosed on CT scan brain. The procedure was done under general anesthesia. Clinical Outcome of ETV was evaluated by the time of discharge and on subsequent follow up visits i.e. monthly for the first three months and then at six months. Any patient who subsequently needed VP shunting after the ETV procedure was described as having treatment failure. We operated 27 patients during our study period. Age ranged from 2 years to 57 years with mean age 20.8 years. There were 16[59.26%] males and 11[40.74%] females. Etiologically, 4th ventricular tumors was present in 9 patients [33.33%], tuberculous meningitis in 8[29.62%], aquiductal stenosis in 7[25.92%], brain stem glioma in 1[3.70%]. cerebellar haemengioblastoma in 1[3.70%] and pineal tumor [3.70%] with infra tentorial extension in 1 [3.70%] patient. The procedure was successful in 24[88.89%] patients and converted to ventriculoperitoneal shunts in 3[11.11%] cases. Post operatively CSF leakage was present in 2 [7.40%] patients, transient memory loss in 1[3.70%], pneumocephalus in 1[3.70%] and pseudomeningocele in 1[3.70%] patients. Endoscopic third ventriculostomy is a good alternative to the VP shunt in cases of non-communicating hydrocephalous. Although ETV does have some complications but these are transient and can be minimized with proper patient selection and meticulous surgical technique

Management of brain abscesses

To find the etiology and outcome of treatment of brain abscesses. Descriptive case series. Department of Neurosurgery, Hayatabad Medical complex Peshawar, from October 2008 to January 2010. This study was carried out on patients of brain abscesses of all ages and both genders. Patients having fungal brain abscess, amoebic brain abscess and tuberculous brain abscess were excluded. Brain abscess was diagnosed on contrast CT scan. Cases of early cerebritis were treated using parenteral antibiotics for six to eight weeks. Surgical treatment consisted of either burr hole aspiration with the help of brain cannula, re-aspiration or craniotomy and excision of abscess capsule. Therapeutic outcome was assessed with CT scan on follow up. Procedure related complications and mortality were also recorded. A total of 73 patients were managed. The commonest age group was from 11-20 year. The mean age was 26.36 +/- 14.1 year [range - 0.16 - 67 year]. There were 46 [63.01%] male and 27 [36.99%] female patients. The majority of brain abscesses were supratentorial [n=65 - 89.04%]. In 8 [11.96%] cases abscess was in infratentorial region. Contiguous focus of infection was responsible for brain abscess in 29 [39.72%] patients, Majority of patients presented with headache [n=30 - 41.09%] and vomiting [n=25 - 34.24%]. Surgical drainage was performed in 70 [95.89%] patients where as 3 [4.11%] patients were treated conservatively. Initially only burr hole aspiration was done in all surgically treated patients. In 60 [85.71%] patients there was complete resolution. Craniotomy was done in 4 [5.71%] cases. There was no mortality in this study. Sixty one [87.14%] patients recovered without complications. Majority of the cases needed surgical intervention. Burr hole aspiration was effective initial surgical treatment. Cases of early cerebritis successfully managed with broad spectrum antibiotics

Efficacy in pain relief; fenestration technique for disc excision

To know the efficacy of disc excision by fenestration method for the relief of lumbar radicular pain in patients with prolapsed intervertebral disc. Descriptive study. Department of neurosurgery of Hayatabad Medical Complex, Peshawar. October 2008 to September 2010. All those patients were included in whom straight leg raising [SLR] sign was less than 60 degree and prolapsed L4-5 or L5-S1 disc on MRI. Patients with multiple level discs, previous history of spine surgery, evidence of lumbar stenosis and cauda equina syndrome were excluded from this study. All patients were operated in knee-chest position under general anesthesia. Efficacy of disc excision was measured using Dennis pain scale. Findings were documented on the day of discharge. Statistical analysis was performed with SPSS [version 10]. One hundred and nine patients were studied. Sixty were male and fifty nine were female patients. Age rang was from 19 to 52 years with mean age 34.31 years. The most common level of involvement was L 4 -L 5 [n=67] followed by L 5 -S 1 [n=42]. Sixty five patients had left sided symptoms while forty four had right sided. Majority of patients presented in Dennis pain scale 4 i.e. 66.97% [n=73]. Twenty patients [18.36%] were in P3 and 16 patients [14.67%] were in Dennis pain scale 5. Complete pain relief [P1], three weeks after disc excision, was achieved in 90 [82.57%] patients .Fourteen patients[12.85%] were in P2 and five [4.58%] patients in P3 according to Dennis pain scale. No patients in this study deteriorated after surgery. Surgical treatment provides quick pain relief in selected patients with prolapsed intervertebral disc. Fenestration with disc excision is quite a reasonable method to surgically treat the indicated cases of prolapsed disc. Fenestration offers complete visualization of nerve root and complete removal of the offending disc. This procedure does not need greater know-how, expertise in instrumentation and techniques

Microvascular decompression in patients with intractable idiopathic trigeminal neuralgia

To evaluate etiology and implications of microvascular decompression [MVD] in patients with intractable idiopathic trigeminal neuralgia. Descriptive case series. Neurosurgery department of Hayatabad Medical Complex, Peshawar from January 2007 to December 2009. Patients with idiopathic trigeminal neuralgia [ITN] irrespective of age and sex, were included in the study. Patients responding to medical treatment were excluded. MRI brain was done for all patients to exclude secondary causes. Microvascular decompression was performed in all patients under general anesthesia. Patients were examined on seventh postoperative day and the clinical findings were documented. Outcome of surgery was declared as successful when there was a commensurate relief of neuralgia paroxysms and deep background pain along with total withdrawal of medications. Fifty two patients were operated for trigeminal neuralgia. There were 23 [44%] males and 29 [56%] females [M:F 1:1.26]. Age ranged between 20-70 years [Mean 56 years]. Right sided neuralgia was present in 34 [65%] cases. In 50 cases [96%] a neurovascular conflict was found. The superior cerebellar artery [SCA] was the cause of compression in 45 [86.53%] patients, anterior inferior cerebellar artery [AICA] in two patients, and one patient each, the vessel involved was posterior inferior cerebellar artery [PICA], basilar artery, and petrosal vein. In 2 patients trigeminal nerve was found encased by tight arachnid adhesions. Trigeminal nerve entry zone was the point of conflict in 38 cases [73.07%]. The mandibular division [V3] was involved in 30 cases [57.7%] followed by maxillary division [V2] in 18 cases [34.61%] and ophthalmic division [V1] in 4 cases [94.23%]. Cerebrospinal fluid [CSF] leakage occurred in 3 cases [5.76%]. One patient developed wound infection. One patient [1.92%] expired in the postoperative period due to mid brain stroke. The main etiological factor of trigeminal neuralgia was vascular compression, especially by SCA, of the 5[th] nerve roots at brain stem. Microvascular decompression is safe and effective therapy for all ages

Outcome of fixateur interne in thoracolumbar trauma

Spinal cord injury [SCI] is a devastating condition often affecting young and healthy individuals around the world. This debilitating condition not only creates enormous physical and emotional cost to individuals but also is a significant financial burden to society at large. The Objective was to study the outcome of spinal fixation with fixateur interne in cases of thoracolumbar spinal injuries in terms of neurological recovery and complications. This Descriptive study was conducted at Department of Neurosurgery, Hayatabad Medical Complex and Postgraduate Medical Institute, Peshawar, from March, 2006 to December, 2007 Study included patients admitted in Neurosurgery Ward HMC, with acute traumatic spinal injuries during the above mentioned period who underwent thoracolumbar spinal fixation with fixateur interne. Name, age, sex, other relevant data, history, examination findings and investigation results were recorded. Postoperative outcome was evaluated taking neurological status, and complications like infection, implant failure and other complications into consideration. Follow-up of 6 months was carried out. There were 31 patients, [18 male and 13 female]. Fall from height [48%], road traffic accidents [26%] and crush injuries [26%] caused the trauma. Most common age group was from 21-30 years age. Fractured vertebrae included 2 D11 fractures, 12 D12 fractures, 13 L1 fractures, 3 L2 fractures and 1 L3 fracture. Mean operative time 80 minutes, mean blood loss 200 ml, mean hospital stay 6 days and mortality rate was 0%. Number of patients with Frankel grade A reduced from 27 to 19 and in Frankel grade E increased from 0 to 4 patients. Only one patient had infection and one patient had implant removal. Fixateur interne is a useful and low-cost implant for fixation of thoracolumbar junction injuries with very easy availability and easy operative insertion and little blood loss. It has excellent post-operative outcome in terms of neurological improvement and a very low complication rate. Mortality rate is minimal

Management of supratentorial brain abscess

To analyze the management out come of symptomatic supratentorial brain abscess by burr hole aspiration. This descriptive study with 40 cases of symptomatic unilocular supratentorial pyogenic brain abscess was conducted at Department of Neurosurgery, Hayatabad Medical Complex, Peshawar from February 2006 to January 2008. Patients having history of headache for more than 14 days and diagnosed with contrast enhanced CT scan were included in the study. All patients were continued on antibiotic and were followed weekly for 1[st] month then monthly till the CT brain showed abscess resolution or no response to treatment was found. The data was recorded and analyzed using SPSS version13.0. The longest diameter on preoperative CT scan was measured in all patients, which ranged from 2.3cm to 4.1cm, with a mean of 3.39cm +/- 0.5. Male to female ratio was 2:1 and mean age was 12.6 +/- 9.7. Out of 40 patients, 13[32.5%] patients required aspiration only once, 18 [45%] required twice and 9 [22.5%] patients for three times. All patients were followed for period of 3 to 7 months; the mean follow up period was 4.4 months +/- 1.033. The treatment was successful in 95% patients as only two patients [5%] did not show any response to treatment and required further excision. Burr hole aspiration is a reasonably good method to treat symptomatic unilocular supratentorial brain abscess that is larger than 2 cm

Coronary artery surgery with or without cardiopulmonary bypass: impact on early outcome

Abstract: during the last 10-15 years, coronary artery surgery without use of cardiopulmonary bypass has gained popularity. Although worldwide incidence of off-pump surgery has remained around 15% , retrospective studies have shown that off-surgery reduces the inflammatory response, mortality and morbidity associated with coronary artery surgery

Objective: to compare early postoperative outcome in patients undergoing coronary artery surgery with or without cardiopulmonary bypass

Methods: a prospective randomized control trial was conducted in Punjab Institute of Cardiology Lahore:-Two hundred consecutive patients. Undergoing coronary artery surgery were randomized in two groups. Group I included 107 patients who underwent coronary artery bypass grafting on CPB and Group II included 93 patients who underwent coronary artery bypass grafting without CPB. Critically ill patients with hemodynamic instability, previous cardiac surgery and patients needing concomitant cardiac procedure were excluded from the study. Incidence of early postoperative [within 30 days] mortality and morbidity [myocardial infarction, bleeding, stroke, arrhythmias, renal and pulmonary complications and infection] were compared among · two groups

Results: in group I, 96 [89.71%] patients were male and 11[10.29%] were female. In group 11, 81[87.09%] patients were male and 12 [12.91%] were female. There was no significant difference in age, preoperative ejection fraction and risk factors for coronary artery disease between two groups. Routine blood tests including Hb, ESR, LFTs, RFTs, Lipid profile, bleeding profile did not show any significant difference among both groups. There was no significant difference in 30 days mortality among two groups, 2.8% in CCABG as compared to 4.3% in OPCAB [p=0.492]. No significant difference in incidence of adverse post-operative cardiac outcomes as Ml [4 [3.7%] in CCABG vs. 7 [7.5%] in OPCABJ, use of intra-aortic balloon pump [2[1.9%] in CCABG vs. 2 [2.2%] in OPCAB] and low cardiac output syndrome [2[1.9%] in CCABG vs. 1 [1.0%] in OPCABJ was found among two groups. No significant difference was observed in amount of bleeding in both groups. The incidence of pulmonary, renal and neurological complications was similar in both groups. Data regarding ICU stay [5.07+3.88 in CCABG vs. 4.23+2.11 in OPCAB] and hospital stay [12.8+8.14 in CCABG vs. 11.55+5.83 in OPCAB] showed insignificant difference

Conclusion: our study has not shown superiority of OPCAB over CCABG with regards to early mortality and morbidity which is consistent with other RCT conducted worldwide. So cautious approach is needed in widespread adoption of OPCAB

Outcome of acute traumatic extradural hematoma

To assess the surgical outcome of acute extradural hematoma in terms of neurological recovery and survival. Study Design: Case series. Place and Duration of Study: Postgraduate Medical Institute, Neurosurgery Unit, Hayatabad Medical Complex, Peshawar, from January to October 2006. Methodology: All patients admitted and operated for acute traumatic extradural hematoma during the study period were included. Demographic data, history, mode of trauma, examination findings, investigations and outcome were recorded. Glasgow coma scale was used for initial assessment and Glasgow outcome scale was applied to assess outcome in terms of neurological recovery in all patients. The follow-up period was 3 months. A total of 30 patients were operated during the period of 10 months including 22 males and 8 females. Patients were in the age range of 20-30 years comprised 30% of all. Most common causes were road traffic accident [50%], fall from height [33%] and assault [17%]. Patients were divided according to the initial Glasgow Coma Score [GCS] after resuscitation. The GCS was 3-8 in 6 patients, 9-12 in 7 patients, 13-15 in 17 patients. Twenty-four patients had good outcome, one patient had moderate disability in the form of left sided weakness, one patient remained in vegetative state, while 3 [10%] patients died. Chi-square test was significant for good outcome in patients with GCS 13-15 [p=0.01] and for death in patients with GCS 3-8 [p=0.01]. Extradural hematoma in head injuries affected young males more commonly. The outcome was better when the initial GCS was in the higher range

Ultrasound guided percutaneous drainage of pancreatic pseudocysts using P.O. catheter

Objective: The purpose of the study is to report the drainage of pancreatic pseudocysts by percutaneous insertion of P.O. catheter under US guidance

Patients and Methods: Between January 1999 and December 2003, 44 patients [28 male, 16 female] with abdominal fluid collection from complicated acute pancreatitis underwent percutaneous ultrasound guided drainage using adult [12 F] or pediatric [10 F] peritoneal drainage catheter

Results: Simple cysts found in 07 patients, haemorrhagic in 20 and infected in 17 patients. Etiology varied from trauma in 09 patients, gallstone in 19 patients, post ERCP 05 patients, biliary ascariasis in 03 and alcohol consumption in 01 patient to idiopathic 07 patients. The tube was kept for drainage from 2 weeks to 11 weeks. The success rate was 84% whereas 12% patients did not improve and required open drainage and lavage. No major complications occurred

Conclusion: The study shows that complicated peripancreatic fluid collections can be safely and effectively treated in most patients with percutaneous P.D. catheter insertion under real time US guidance

Treatment of congenital hydrocephalus

Excessive accumulation of CSF in brain resulting in increase ICP is called hydrocephalus. The conclusions is common in developing countries. To stream line the treatment policies we conducted this study in Lady Reading Hospital, Peshawar.Fifty patients of congenital hydrocephalus were studied. 48% were male and 52% were females. Ages were from 09 days to 13 months. Cases had communicating type of hydrocephalus and 20% obstructive hydrocephalus. Eighty percent patients were diagnosed with the help of skull ultrasound and computerized tomography scan. In all cases ventriculoperitoneal shunting were performed. This study was conducted for period of two years. All cases had good outcome and no mortality. Shunt obstruction and infections were the main complications. Ventriculoperitoneal shunting is the treatment of choice in hydrocephalus

Neurological manifestations of Wilson's disease

To study the frequency of various neurological manifestations in patients with Wilson's Disease.Patients suspected of having Wilson's disease were admitted to the Neurology unit of Postgraduate Medical Institute, Lady Reading hospital, Peshawar, for a full work up for Wilson's disease. Only those patients who had neurological signs or symptoms of Wilson's disease were included in this study. Out of 15 patients 9 were female and 6 were male, ranging in age from 8 to 26 years, with mean age of 15.6 years [SD +/- 5.82]. Most common neurological features were tremors followed by rigidity, dysphagia/drooling, speech or gait problems. All patients had low serum ceruloplasmin level and Kayser-Fleischer corneal rings. Liver involvement in the form of cirrhosis was found in 13 [86.7%] patients on ultrasonography, since no liver biopsy was done it could not be determined whether the remaining two patients had liver involvement or not. Neurological manifestations are not uncommon in Wilson's disease. It should be considered in patients of any age presenting with unusual liver, neurologic or psychiatric abnormalities. It should especially be looked for in children and other young patients with extrapyramidal signs or symptoms

Hypolipidemic therapy in patients of coronary heart disease

Ten patients of coronary heart disease and having hyperlipidemia of mild to moderate degree were included in the present study after their consent. They were divided into three groups. Subjects in group a, b and c were kept on lopid, mevacor band bezalip respectively for fifteen days with the consultation of physician. Change in the blood level of Triglycerides [Decrease] and High density lipoprotein [Increase] produced as a result of lopid therapy was much more pronounced as compared with that produced as a result of mevacor therapy, while mevacor was found to be more effective in lowering the level of cholesterol and low density lipoprotein. Bezalip also produced a marked change in blood lipid profile similar to that seen as a result of lopid therapy