Posterior occipito cervical decompression with fixation [ and fusion in Cranio vertebral junction compression

Objective: To find out the clinical outcome of posterior decompression with occipitocervical fixation ani fusion in patients with Craniovertebral junction instability

Methods: Eighty consecutive patients of cranio vertebral junction [CVJ] compression were treated the department of neurosurgery, Jinnah Postgraduate Medical Centre [JPMC], Karachi over a periodol 05 years from 1st January 2012 till 31st August 2016. All patients underwent posterior decompression witty occipitocervical fusion [OCF] and fixation. The clinical outcome was assessed by Japanese Orthopedic Association [JOA] score and grading

Results: Out of 80 patients with CVJ instability, 64 [80%] were due to non traumatic causes, while II [20%] were secondary to trauma. All 80 patients [100%] showed post operative relief in pain. Sixty to [80%] patients showed improvement in power post operatively while six [7.5%] had no change, four [51] showed deterioration and six [7.5%] patients expired. Sixty four [80%] patients had improvement of the J01 scores at last follow-up. According to etiology, the JOA score for patients with trauma improved in 12[7S] patients and 52[81.25%] for non traumatic causes while six patients [7.5%] expired. Fusion was achieved 64 [80%] patients at last followup

Conclusion: Posterior decompression with occipitocervical fusion and fixation is safe and can be recommended in cases of CVJ compression

Postoperative functional outcome of intradural extramedullary spinal tumors through posterior approach

Objective: To determine functional outcome of intradural extramedullary spinal tumors in patients undergoing excision through the posterior approach alone

Study Design: Interventional study

Place and Duration of Study: Neurosurgery Department, JPMC, Karachi, from March 2011 to February 2014

Methodology: Patients with intradural extramedullary spinal tumors [IDEM], confirmed on MRI, were admitted through Outpatient Department. Those with bleeding disorders, diabetes mellitus, previously operated and with no histopathological evidence of tumor on biopsy, were excluded. Clinical signs, symptoms and location of the tumor were noted. These patients then underwent laminectomy and excision of tumor through the posterior approach, regardless of the location or type of tumor. Transpedicular screw was placed where the tumor was so large, as to cause posterior instability. The functional outcome was evaluated by assessment of Medical Research Council [MRC] Scale for Muscle Strength preoperatively and at 6 months follow-up postoperatively. Good outcome was labelled when there was improvement from previous grade before surgery to higher grade, as assessed by muscle strength on follow-up at 6 months after surgery

Results: The mean age of the 38 patients was 42.6 +/- 10 years. Majority were females [68.42%]. Meningioma was the commonest tumor [63.15%]. The commonest location was thoracic spine [73.68%]. Backache was present in all [100%] patients, motor weakness in 30 [78.92%] patients, sensory disturbance in 5 [13.5%] patients, sphincter disturbance in 7 [18.42%] patients, and shortness of breath in 1 [2.63%] patient. Preoperatively, there were 10 patients [26.31%] in grade 3, 9 [23.68%] patients in grade 0, 8 [21.05%] in grade 1, 7 [18.42%] patients in grade 2. After 6 postoperative months, there were 23 [60.52%] patients in grade 5, 5 [13.15%] patients in grade 3, 5 [13.15%] patients in grade 2 and 2 [5.26%] patients in grade 1. Postoperative complications were CSF leak, respiratory distress, wound infection and incontinence

Conclusion: Functional outcome of intradural extramedullary spinal tumors was found to be good

Dandy-walker malformation: a clinical and surgical outcome analysis

To determine the clinical presentations, complications and mortality in patients with Dandy-Walker Malformation [DWM] after surgery i.e., shunt with y-connector. Case series. Neurosurgery Ward, JPMC, Karachi, from January 2009 to December 2013. Cases of DWM, with associated hydrocephalus, further confirmed on CT scan of brain, were admitted through OPD. Those who were previously operated, those with other associated co-morbid or anomalies were excluded from this study. Combined drainage of the ventricular system and posterior fossa cyst, via dual shunt i.e. cystoperitoneal and ventriculoperitoneal shunt with y-connector was performed in all patients. Complications and mortality after surgical intervention in these patients were noted upto one month after surgery. The data analysis for descriptive statistics was done on SPSS version 20. In this study of 70 patients, majority of the patients were female aged between 1 - 2 years. Hydrocephalus was the predominant symptom as being present in all patients, followed by cerebellar signs in 60 [86%], and other in 5 [7.14%] patients. Complications of surgery were infection and shunt fracture dislocation in 7 [10%] each, malpositioning and shunt blockage in 6 [8.5%] each within one month of surgery, intracranial haemorrhage in 5 [7.14%] patients. Only one patient [1.42%] expired after surgical intervention. In DWM, the commonest presentation is that of hydrocephalus. Shunt malfunction and infection are the commonest complication after shunting. Dual shunt with y-connector has the lowest mortality when compared with other methods for treatment of shunt with y-connector

Posterior Fossa Decompression with Duraplasty in Chiari-1 Malformations

Objective: To evaluate the symptomatic outcome after PFD [Posterior Fossa Decompression] with duraplasty in Chiari-1 malformations. Study Design: Case series. Place and Duration of Study: Department of Neurosurgery, JPMC, Karachi, from July 2008 to September 2012. Methodology: This included 21 patients of Chiari 1 malformations admitted in department through OPD with clinical features of headache, neck pain, numbness, neurological deficit, and syringomyelia. Diagnosis was confirmed by MRI. PFD followed by C1 laminectomy with duraplasty was done in all cases and symptomatic outcome was assessed in follow-up clinic. Results: Among 21 patients, 13 were females and 8 were males. Age ranged from 18 to 40 years. All the patients had neck pain and numbness in h and s. Only 3 patients had weakness of all four limbs and 12 with weakness of h and s. Symptoms evolved over a mean of 12 months. Syringomyelia was present in all cases. All patients underwent posterior fossa decompression with duraplasty with an additional C1 laminectomy and in 2 cases C2 laminectomy was done. Syringo-subarachnoid shunt was placed in one patient and ventriculo-peritoneal shunt was placed in 2 patients. Pain was relieved in all cases. Weakness was improved in all cases and numbness was improved in 19 cases. Syringomyelia was improved in all cases. Postoperative complications included CSF leak in 2 patients and wound infection in one patient. However, there was no mortality. Conclusion: Posterior fossa decompression with duraplasty is the best treatment option for Chiari-1 malformations because of symptomatic improvement and less chances of complications. Key Words: Chiari-1 malformation. Posterior fossa decompression. Duraplasty.

Zuckerkandl tubercle: an important landmark in thyroid surgery

To find out the frequency of Zuckerkandl Tubercle [ZT] and the position of recurrent laryngeal nerve with reference to ZK. Cross-sectional observational study. Surgical Ward-3, Jinnah Postgraduate Medical Centre [JPMC], Karachi, from June 2010 to August 2011. Patients having goiter, aged between 12 - 60 years were admitted through OPD and operated after informed written consent. After admission, they underwent surgery. ZT and recurrent laryngeal nerve position i.e. whether medial, lateral or posterior to ZT was identified during surgery. Data was collected on pre-designed proforma and analysed on SPSS version 15 for descriptive statistics. Out of the 84 patients ZT was found in 52 [61.90%] patients. Nineteen patients had grade-I [less than 0.5 cm], 22 [42.3%] had grade-II [0.5 - 1 cm] and 11 [21.1%] had grade-III [more than 1 cm] ZT. During surgery, 33 [63.4%] patients had recurrent laryngeal nerve medial to ZT, 15 [28.8%] patients had lateral and in 4 [7.6%] patients recurrent laryngeal nerve was engraved posteriorly. Zuckerkandl tubercle was found in about 62% cases; recurrent laryngeal nerve was located pre-dominantly medial to ZT

Comparison of usefulness of topical capsicum ointment with diclofenac gel in the treatment of mastalgia

Objective: to compare the usefulness of topical capsicum ointment with diclofenac sodium gel in the treatment of mastalgia

Study design: comparative study

Place and Duration of study: ward-3 Surgical Unit I, Jinnah Postgraduate Medical Center Karachi, from September 2011 to March 2012

Methodology: women with mastalgia were assigned into two groups. Group A received topical diclofenac sodium gel while group B received capsicum ointment. Severity of pain was assessed on visual analogue scale [VAS] of 0-10. Chi-square test was applied to compare the outcome of two groups and p-value <0.05 was considered statistically significant

Results: a total of 72 women were enrolled. Each group had 31 participants. The mean age of the patients was 27.47 +/- 8.08 year [95% CI: 25.57 to 29.37]. Duration of disease was 38.66 + 9.34 months and 39.20 +/- 11.12 months in group A and B respectively. Of total study participants, 41[57%] improved with treatment. In diclofenac group more patients reported pain relief than capsicum group [69.4% vessus 44.4%-p-value:<0.001]

Conclusion: Topical diclofenac sodium and capsicum ointment both were found effective but diclofenac sodium was more effective in relieving mastalgia

Surgical outcome of posterior fossa brain tumors

To determine the surgical outcome of posterior fossa brain tumors. Descriptive case series. Department of Neurosurgery, Jinnah Postgraduate Medical Center Karachi, from April 2012 to October 2012. The data of 66 patients managed during the study period was analyzed. Patients were divided into extra and intra-axial groups. All patients underwent surgery. The outcome was measured as good and poor two months after discharge from the hospital. Out of 66 patients, 41[62%] were males and 25 [38%] females. The mean age of the patients was 31.21 +/- 18.49 year. With respect to age groups, good surgical outcome was observed in 11 to 30 year and 41 to 50 year of age. Good surgical outcome was similar in both the genders. Vestibular schwanoma was the commonest tumor [72.2%] in extraaxial variety of tumors. Good functional outcome [80%] was observed following surgery in extra-axial group of patients. No mortality occurred in extra-axial group while two patients died in intra-axial group. Medulloblastoma [29.26%] and pilocytic astrocytoma [29.26%] were the commonest tumors in intra-axial group. Mortality occurred only in 2 [4.87%], recurrence in 2 [4.87%] and unresolved hydrocephalus in 3 [7.31%] patients. Improvement in morbidity was noticed in 31[75.6%] patients after surgery. Factors associated with good outcome was age > 10 years and type of tumor

Decompressive craniotomy and duraplasty in patients of traumatic bifrontal contusions

To find the outcome of bifrontal decompression craniotomy [DC] for the treatment of traumatic bifrontal contusions. Descriptive case series. Department of Neurosurgery Jinnah Postgraduate Medical Center [JPMC] Karachi, from January 2011 to March 2014. This study included patients with bifrontal contusions secondary to trauma admitted through A and E department, aged between 14 year to 60 year with confirmation on CT scan having Glasgow Coma Scale [GCS] scores between 6-12. Patients who were unfit for surgery or anesthesia and those with coagulation disorders, were excluded. Patients underwent bifrontal DC with evacuation of contusions followed by duraplasty. The age, gender, preoperative size of the contusion, GCS on admission, postoperative complications and Glasgow Outcome Scale [GOS] score after 6 months of surgery were recorded. This study was conducted on 50 patients. Trauma was the commonest type of injury in 43 [86%] cases. Mostly patients were males [84%]. Majority of patients were between 21 year and 40 year of age. The GCS score before surgery in these patients was 9 in 13 [26%] patients, 10 in 16 [32%] patients, 11 in 11 [22%] patients, 12 in 6 [12%] and 13 in 4 [8%] patients. The most common size of contusions was 4 and 5 cms, both on right and left side. Of these, none of the patients required reoperation. Three died after aspiration within the postoperative time span of day 5-7. Good recovery was seen in 40 [80%] patients, moderate disability in 6[12%], severe disability in 1 [2%], persistent vegetative state in 2 [4%] and death in 1 [2%] patient. This study showed feasibility and efficacy of DC in bifrontal brain contusions secondary to traumatic brain injury [TBI] with good outcome

Carcinoma thyroid in multi and uninodular goiter

To determine the frequency and profile of carcinoma in multi-nodular goiter and solitary thyroid nodule. Case series. Surgical Unit-I, Ward-3 of Jinnah Postgraduate Medical Center, Karachi, from January 1999 to January 2009. Cases with solitary thyroid nodules and multi-nodular goiter were included. Patients under 12 years of age, cystic benign lesion in solitary thyroid nodules or those multi-nodular goiters, which were not causing pressure symptoms, cosmetic problems or sign of malignancy were excluded. In solitary thyroid nodule, hemithyroidectomy was done and if histopathology examination revealed carcinoma thyroid then completion thyroidectomyw as done. In multi-nodular goiter sub-total thyroidectomy done. Results were described as frequency percentages and mean. Out of 379 patients of multi-nodular goiter only one patient was found to be papillary carcinoma [0.25%]. In 220 patients of solitary thyroid nodules, 93 patients were diagnosed as carcinoma of thyroid [42.27%]. Others diagnosed in solitary thyrid nodule were thyroid adenoma, colloid goiter, thyroiditis and multi-nodular goiter. The frequency of papillary carcinoma in 65.95% occurring females of 12-30 years of age and being multifocal in 6.45% follicular carcinoma in 23.49%, medullary carcinoma in 7.44%, analplastic carcinoma in 2.12% and lymphoma in 1.01%. Female were predominantly involved and papillary carcinoma was common in 12-30 years of age [7.63%] and follicular was common in 30-40 years of age [68.18%. 6.45% of papillary carcinoma was found to be multifocal in nature. Frequency of carcinoma of thyroid is very high in solitary thyroid nodule [42.27%], but markedly low in multi-nodular goiter. Papillary carcinoma is the most common variety, most of in younger female

Outcome of stapled haemorrhoidectomy versus Milligan Morgan's haemorrhoidectomy

To compare the postoperative outcome of stapled haemorrhoidectomy and conventional Milligan Morgan's open haemorrhoidectomy. Comparative study. Surgical Unit 1, Ward-3, Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi, from March to September 2006. Sixty patients of late 2nd, 3rd and 4th degree haemorrhoids were selected for admission from the outpatient department after taking informed consent. Patients with concomitant anal disease [e.g. fissure, abscess, fistula, ano-rectal cancer etc.] were excluded. Two groups of thirty each were made, one for Milligan-Morgan open haemorrhoidectomy and another for stapled haemorrhoidectomy, in which excision of a ring of mucosa proximal to the haemorrhoid[s] was done thus, interrupting the blood supply but maintaining continuity of the rectal mucosa. The operative time was measured in minutes. Postoperative pain was assessed through VAS. Bleeding was measured as no, mild, profuse. Other post-operative complications during hospital stay like urinary retention, anal stenosis etc. were noted. Student t-test, chi-square test and repeated measured analysis of variance were applied to compare the variables. The mean age was 40.7 +/- 11.6 years. A majority [53.3%] of patients [combined% in both groups] had third degree haemorrhoid. The mean length of operative time was found statistically insignificant between open and stapled groups [19.6 +/- 5.9 vs. 22.4 +/- 7.2 minutes, p=0.974]. However, the mean length of postoperative hospital stay was significantly less in the stapled than open haemorrhoidectomy group [3.37 +/- 2.2 vs. 2.03 +/- 0.81 days, p=0.003. Mean postoperative pain [observed by VAS] in the stapled group was significantly less than the open haemorrhoidectomy group [4.43 +/- 1.25 vs. 7.37 +/- 0.72]. The proportion of postoperative bleeding, infection, anal tag, urinary retention, tenderness on digital rectal examination and wound discharge was higher in open than stapled haemorrhoidectomy group, but statistically insignificant [p < 0.05]. There was a significant difference between Milligan Morgan's and stapled haemorrhoidectomy for postoperative pain and hospital stay. However the mean length of operative time was insignificantly different

case of pseudotumorous form of ascaris

A 35-year-old woman presented with lower abdominal pain and amenorrhoea. CT showed a thick walled lobulated mass with Ascaris adjacent to caecum along with the presence of a left ovarian mass. The peroperative findings were a tubular mass with central tunneling containing an Ascaris lumbricoides. Left ovary showed a haemorrhagic cyst. Biopsy of the mass showed acute on chronic granulomatous inflammation and the worm was found to be female. This was a rare case of Ascaris lumbricoides presenting as a pseudotumorous mass

Early experience of sentinel lymph node biopsy in breast cancer

To assess the results of sentinel lymph node biopsy in breast cancer. Case Series. Surgical Ward 3, Jinnah Postgraduate Medical Centre Karachi, from April 2007 to March 2009. In this study patients with biopsy proven carcinoma breast and clinically negative lymph nodes in the axilla were included. Patients with history of previous breast surgery, clinically palpable lymph nodes, Stage IV disease, bleeding disorders, chronic liver disease or history of allergic reaction to the dye were excluded. The study patients underwent sentinel lymph node mapping and dissection. One ml of gentian violet or methylene blue dye injected into the peritumoral area followed by one minute massage. Simple mastectomy or wide excision with axillary clearance was done after 30 minutes of injection. This study was conducted on 35 patients with the age range from 28 years to 68 years. In all the patients diagnosis was infiltrating ductal carcinoma. Wide local excision with axillary clearance was possible in only two patients with clinically stage 1 disease. In rest of the patients simple mastectomy with axillary clearance was done. According to the tumor size; T1 was observed in 15 patients, 72 in nine, T3 in six and T4 in five patients. In all patients [n 15] with T1 tumor, stained lymph node was positive in eight patients while tumor metastasis in the remaining lymph nodes removed by axillary clearance showed involvement in six patients. In patients with T2 masses, tumor involvement was seen in both groups of lymph nodes in six patients. In three patients with T4 tumor, sentinel lymph nodes were negative for tumor metastasis however in rest of the lymph nodes tumor involvement was seen in four patients. In patients with T3 masses, three showed involvement of the entire axillary lymph node group and sentinel lymmph node as well. If sentinel lymphnode is involved by the tumor, axillary clearance should be done irrespective of the tumor size. Sentinal node biopsy should be avoided in patients with T4 lesions

Unusual presentation of choriocarcinoma

Choriocarcinoma is a rare malignant genital tract tumor, arising in the uterus or in the testis. These tumors in women usually follows a pregnancy. It is more common after a molar pregnancy. A 35 years old married woman was admitted with two weeks history of bleeding per rectum. Patient was explored via a midline incision. A 2x2 cm polypoidal lesion was found in terminal ileum and a haemorrhagic cystic mass seen in upper pole of right kidney. Uterus was bulky. Heal lesion was resected and anastomosis done. Excision Biopsy was taken from the renal mass, conserving the kidney. Resected Heal tissue and kidney mass were reported as Choriocarcinoma

Tubercular fistula-in-ano

To determine the frequency of tuberculosis in recurrent fistula-in-ano. Case series. This study was conducted in Surgical Ward-3, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from 1998 to 2007. The study included 100 cases of recurrent fistula-in-ano not responding to conventional surgery. Patients with other co-morbidities such as diabetes mellitus, bleeding disorders or with the evidence of pulmonary, abdominal or intestinal tuberculosis were excluded from this study. Fistulogram was performed in all patients. All the patients were subjected to fistulectomy followed by histopathology of the resected specimen. Thereafter, confirmation of the disease, anti-tuberculous treatment was immediately started and response to treatment was observed after 6 months. Out of the 100 studied patients, 11 cases had biopsy proven tuberculosis in the fistula. All the patients were male. The fistulae were low type, single and usually located posteriorly [n=9] with everted margins. Ten were located within 3 cm of anus. Fistulogram revealed single internal opening. Comparative statistics of tuberculous fistula-in-ano with fistulas due to specific inflammation revealed no major differences. The diagnosed patients of tubercular fistulae-in-ano were observed for at least 6 months after starting anti-tuberculous treatment. They all responded well to anti-tubercular treatment and the fistulae healed without any complication such as recurrence or anal stenosis within 6 months. Tuberculosis should be suspected in case of recurrent fistulae-in-ano, so as to avoid unusual delay in the treatment and miseries to the patient. Appropriate anti-tuberculous therapy leads to healing within 6 months