Adjuvant therapy for old age glioblastoma patients

Since the advent of Temozolomide [TMZ], optimum management for elderly patients with newly diagnosed Glioblastoma [GBM] is still elusive. The object of this study was to clarify outcomes of present management. Long term prospective study. This study was carried out on patients who were treated at the Aseer Central Hospital Abha KSA, Frontier Medical College Abbottabad, Women Medical College Abbottabad and those operated privately between August 2001 and August 2013. This is a long term study of 41 consecutive cases involving patients aged 55 years or more with newly diagnosed GBM. The patients' median age was 61 years [range 55-87 years]. Twenty nine patients underwent resection and rest underwent biopsy. Patients with deep-seated lesions and multifocal lesions [12 patients 29.26%] were preferably biopsied than gross total resection. Eighteen patients [43.90%] were treated with chemotherapy [mostly TMZ] with radiation therapy [RT] and Six [14.63%] with RT alone. Three patients [7.31%] received only palliative care after surgery. New neurological deficits developed in 5 patients [12.19%]. Postoperative hemorrhage occurred in 8 patients [19.51%], all of whom underwent biopsy. Chemotherapy complications occurred in 19.51% [Advanced hematological complications in 14.63%]. The overall median values for progression-free survival and overall survival were 4.5 and 6 months respectively. Younger age, single lesion resection and adjuvant treatment were associated with better overall survival. Only adjuvant treatment was significantly associated with prolonged progression-free survival. With combined therapy containing resection, RT, and chemotherapy, the median progression-free survival and overall survival were 7.5 and 11 months, respectively. The prognosis for GBM worsens with increasing age in elderly patients. When high risk factors are present, resection with adjuvant treatment are associated with prolonged survival but are with associated risks. Advanced age alone should not preclude optimal resection followed by adjuvant radio-chemotherapy

Surgical outcome of thoracic and thoraco-lumbar injuries of the spine: a case for posterior instrumentation

Management of unstable thoracic spine fractures remains controversial. The results of treatment of injuries of the thoracic and thoraco-lumbar spine with neurological involvement have been evaluated. Advantage of pedicle screw fixation are that neural canal dissection is not required and hence potential neural element injury by intracanal instrumentation avoided. To evaluate outcome of pedicle screw fixation and bony fusion for the surgical management of traumatic thoracic and lumbar spine fractures, their respective performance and complication rates. This study was carried out in the Department of Neurosurgery at Assir Central Hospital Abha KSA from January 2003 to December 2004. Twenty one patients with 32 individual vertebral injury levels [T2-L4] treated conservatively or with transpedicular spinal stabilization and bone fusion were evaluated during a 2-year consecutive period. Male: female ratio was 15:6 [2.5:1]. A total of 42 pedicle screws were placed from T2-L4 levels. Fracture healing and radiographic stabilization occurred at an average of 4.8 months after the initial operation. Of the patients treated conservatively, [5]35% showed significant neurological improvement compared to [6] 38% of those treated surgically, but the latter group contained a much higher proportion of incomplete lesions with a far better prognosis. There were no reported cases of hardware failure, loss of reduction, or painful hardware removal. These results provide evidence that with appropriate preoperative radiographic evaluation of pedicular size and orientation using computed tomography, transpedicular instrumentation is a safe and effective alternative in the treatment of unstable thoraco-lumbar [T2-L4] spinal injuries. The place for early operation might be still further restricted

Translation and validation study of the first modified pakistani version of the neck disability index and its revalidation

The purpose of our study was the translation and validation of the Neck Disability Index in our specific cultural background. The Pakistani Urdu version of Neck Disability Index [NDI] was tested for validity and reliability. The Neck Disability Index [NDI] is a valid and reliable tool, designed to measure disability in routine life activities due to neck pain. International standards were followed for the translation strategy comprising forward translations, reconciliation, backward translation and pre-testing steps. The translation of the original questionnaires was performed in accordance with published guidelines and this was adapted to cultural differences in the patient population. These procedures resulted in the Pakistani modified version of the NDI. comparative study. This study was carried out at the Department of Neurosurgery Outdoor Clinics at Benazir Bhurto Shaheed Teaching Hospital Abbottabad from April 2007-March 2009. In the first stage, Fifty five patients [32 men, 23 women] were included over two years period at the Department of Neurosurgery Outdoor Clinics at Benazir Bhutto Shaheed Teaching Hospital Abbottabad attached with Women Medical College Abbottabad. Seventeen patients were suffering from acute phase after a neck sprain, 20 had chronic neck pain and 18 had no neck pain but had other musculoskeletal symptoms. On 3 occasions, the patients completed the Neck Disability Index and other surveys. Levels of sensitivity, test-retest reliability and validity were acceptable. In the next stage, Thirty-eight patients [16 men, 22 women] were included in a study of the modified version, twenty patients with acute neck sprain and 18 with other musculoskeletal symptoms filled out to test the modified version of the Neck Disability Index, which provided a more specific measure of disability due to neck pain. We have accumulated enough evidence to show that the Urdu version of the Neck Disability Index measures disability in activities of daily living in patients with neck pain in a reliable, valid and responsive manner. The questionnaire is considered a useful tool for research and clinical settings in local or international studies since its psychometric properties are comparable with other versions validated in different countries. The Pakistani version of NDI is a reliable and valid instrument to measure psychometric properties and functional status in Pakistani patients suffering from neck disability. Being a simple and fast scale, its use can be recommended in a clinical setting and future outcome studies in Pakistan

Sacroiliac joint syndrome in the differential diagnosis of low back pain and sciatica

Sacroiliac Joint syndrome [SIJS] is an extraspinal cause of low-back and lower-extremity pain that can present in so many different ways. The constellation of symptoms attributed to SIJS includes pain referral to numerous anatomic regions. Specific pain referral zones reported include the Posterior superior Iliac Spine [PSIS],[1] lower Lumbar Region,[2,3,4,5,6,7] Buttock,[3,,4,7,13,14,21] Groin and Medial Thigh [13,21], Posterior Thigh [8,13,14,22] Lower Abdomen [9,14], Calf and foot. To determine the origin of pain of the sacroiliac joint and to differentiate it from pain due to degenerated lumbar disc disease. Long term, prospective study. This study was conducted in the Department of Neurosurgery, Women Medical College, Abbottabad from August 2006 - July 2013. Fifty Three patients who satisfied clinical criteria and demonstrated a positive diagnostic response to sacroiliac joint injections were included in an attempt to solve the dilemma in neurosurgical patients when differentiation between discogenic pain and one origination from sacroiliac joint [Sacroiliac joint syndrome -SIJS] is difficult. Clinical and radiological differentiation were not so remarkable between two conditions and based on these the diagnosis can go either way. Each patients' pre-injection pain description was used to determine areas of pain referral and then sacroiliac joint was blocked by injections to see whether patients are still experiencing the Discogenic pattern of LBP and sciatica. To block sacroiliac joint by injection and then Invoking patients' pain by clinical tests to see the origin of pain. Seventeen men [36.0%] and 36 women [64.0%] were included with a mean age of 42.5 years [range, 20 to 75 yrs] and a mean symptom duration of 18.2 months [range, 1 to 72 months]. Twenty patients [37.73.0%] described buttock pain and 33 patients [62.26%] described lower lumbar pain. Groin pain was described in 7 patients [13.20.0%]. Twenty-five patients [47.16%] described associated lower-extremity pain. Fourteen patients [26.41.0%] described pain distal to the knee, and 6 patients [11.32%] reported foot pain. A statistically significant relationship was identified between pain location and age with younger patients more likely to describe pain distal to the knee. It was possible to identify a patient population consisting 15 patients [28.30%] who were actually suffering from SIJS and their treatment streamlined accordingly. After treating the sacroiliac joint and restoring symmetrical hip rotation, these patients no longer complained of low back pain. Pain referral from the sacroiliac joint does not appear to be limited to the lumbar region and buttock. The variable patterns of pain referral observed may arise for several reasons, including the joint's complex innervation , sclerotomal pain referral, irritation of adjacent structures, and varying locations of injury with the sacroliasjoint

CSF rhinorrhoea; unilateral craniotomy and repairs

Cerebrospinal fluid [CSF] Rhinorrhoea has 2% incidence in closed head trauma and 9%in penetrating head injuries. Most traumatic leaks cease spontaneously within 24-48 hours following insult. Exact knowledge of the anatomy of the underlying problem is the key to successful management. Improvements in neuroradiology have made operative procedure more precise. This prospective study was carried out to evaluate the efficacy of CT-Cisternogram and Multiplaner MRI to localize the dural and bony defect in patients who presented with spontaneous or traumatic CSF Rhinorrhoea. Twelve patients from January 89 to October 98 underwent unilateral craniotomy, dural repair with or without pericranial graft. One patient developed Hydrocephalus required Ventriculo-peritoneal shunt. We conclude that unilateral craniotomy is suitable for dural repair if precise localization is known by CT Cisternogram or Multiplaner MRI. MRI is non-invasive as compared to Radio-nuclide isotope scan or CT Cisternogram but still provides adequate information