Impact of depressed skull fracture surgery on outcome of head injury patients

Objective: To assess outcomes in surgically managed patients with depressed skull fractures and associated moderate to severe head injury

Methods: The study was conducted in the Department of Neurosurgery Jinnah Postgraduate Medical Centre, Karachi, from January 2016 to December 2017. We analyzed 90 patients with depressed skull fracture managed surgically from January 2015 to December 2016. The patients selected for this study belonged to all age groups with clinically palpable depressed skull fracture confirmed by CT brain with bone window. Outcome was assessed by Glasgow outcome score

Results: Total 90 patients were included in the study. Sixty [66.7%] were male and 30 [33.3%] were female with mean age of years 27.58+11.329. Among 90 patients, 38.8% were aged between 21 and 30 years. Road traffic accident was seen in 72 [80%] patients. The commonest site of fracture was frontal region in 50 patients [55.6%]. GCS improved post operatively on comparison to preoperative. Five patients expired

Conclusion: Depressed skull fracture is common neuro surgical issue. Timely surgical management gives excellent results by decreasing morbidity and mortality

Endoscopic trans-sphenoidal surgery: efficacy and response in pituitary adenoma

Objectives: The purpose of the study was to access the efficacy and response of the endoscopic transsphenoidal surgery in pituitary adenomas

Methods: It was descriptive case study, conducted at Neurosurgery Department in collaboration with the Endocrine Unit [Medical Unit-II] Of Jinnah Post Graduate Medical Center Karachi from January 2015 to July 2017. Patients with sellar, supra sellar and para sellar tumors were enrolled in the study. Patients with prolactinoma and recurrent pituitary tumors were excluded. Data was analyzed using SPPS 17

Results: Sixty three patients were included in the study with mean age of 42+/-8.34 years. There were 40[63.5%] male patients and 23[36.5%] female patients with pituitary adenoma. Headache and visual impairment were the main presentation 55[87.3%] and 56 [88.8%] respectively. Out of all these patients the pituitary adenomas, 51[81%] patients had non secretory and 12 [19%] patients had secretory tumor. Out of these pituitary adenomas 53[84.1%] were macroadenomas and 10[15.9%] were microadenoma. Post operatively marked improvement in the headache was in all 100% patients and vision improved in 54 [96.4%]. The most common post operative complication was cerebrospinal fluid [CSF] leak in 10 [15.9%] with 44 [69.8%] having no post complications at all. Mortality was reported to be just 1.6% i-e one patient

Conclusion: The endoscopic transsphenoidal approach for pituitary adenoma is the safest procedure with marked improvement in complications and reduction in patient's hospital stay

Lateral mass screw fixation in cervical spine injury

Objective: To determine clinical outcome in patients with cervical injury after lateral mass screws fixation in a tertiary care hospital

Methods: This study included 88 patients, with cervical injury confirmed radiologically. Patients <12 or >70 years, with traumatic discs, cord compression without subluxation and previously operated on cervical spine were excluded from this study. All patients underwent fixation with lateral mass screws through posterior approach under fluoroscopic guidance. Frankel grading was used to assess the clinical status of these patients pre-operatively and post-operatively

Results: There were 60[68.18%] males and 28[31.8%] females. The ages varied from 18 to 55 years with a mean of 32 yrs +/- 8 yrs. The most common level of injury was C5-C6 in 46[52%] patients. According to Frankel grading system, 35 [39.8%] patients were placed in Grade A, 15[17.05%] in Grade B, 22[25%] in Grade C, 12 [13.6%] in Grade D, four [4.5%] in Grade E on admission. Postoperatively, 16 [18.2%] patients were placed in Grade A, 23 [26.1%] in Grade B, eight [9.1%] in Grade C, nine [10.2%] in Grade D and 26[29.6%] patients in Grade E with an overall improvement in neurological function in 51[58%] and power in 37[42%] patients. The major complications encountered were respiratory infections in 10[11.36%] and wound infection in four [4.5%] while eight [9.1%] patients expired

Conclusion: Lateral mass screws technique is a safe and effective method for cervical fixation after proper reduction

Outcome of burr-hole aspiration of brain abscess

Objective: To determine the clinical outcome of burr-hole aspiration of brain abscess

Methods: We analyzed 100 cases of intracranial abscess, treated surgically from January 2015 and October 2016 at Jinnah Postgraduate Medical Centre [JPMC]. All patients were treated with burr hole aspiration. Medical records were analyzed for demographics, clinical presentation, predisposing factors, abscess location on imaging and clinical outcomes were charted

Results: The study included 100 patients with 73 [73%] males and 27[27%] females with a mean age of 36.69+10.96 years. Mean duration of signs and symptoms was 8.50+/-4.2 days. The most common presenting complaint was altered sensorium in 70 [70%] patients and commonest source of infection was otitis media een in 27 patients [27%]. The GCS on presentation was 13 in 57 [57%] cases. The parietal region was the most common site in 43 patients [43%], followed by frontal region in 33 patients [33%].Complete resolution of abscess with recovery of preoperative neuro-deficit was seen in 77 [77%] patients and recovery with major neuro-deficit was observed in 10 [10%] cases while 13 [13%] patients expired

Conclusion: Early diagnosis, optimum follow-up and timely burr-hole aspiration are the keys in the proper management of brain abscess

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

Subclinical Hypothyroidism: Frequency, clinical presentations and treatment indications

Objective: To determine the frequency, modes of clinical presentation and indications for replacement therapy in a cohort of patients with subclinical hypothyroidism [SCH]

Methods: This study was conducted at the Endocrine and Diabetes Unit of Jinnah Postgraduate Medical Centre from September 2007 - October 2015. This was a retrospective chart analysis of prospectively collected data in which the medical records of 4448 patients who had presented to the Endocrine Clinic from 2007 to 2015 were reviewed. A total of 2760 [62.05%] patients were diagnosed with thyroid disorders, whereas 260 [9.42%] patients had SCH. The SCH patients were between the age of 12 to 70 years; TSH was >4mlU/l with normal levels of FT3 and FT4. Patients were enrolled using a predesigned structured proforma. Those having chronic systemic diseases were excluded from this study. SPSS 13 was used to evaluate the data

Results: Female patients comprised 93.8% [244 patients] of those with SCH, whereas only 6.2% [16 patients] were male. Common presenting symptoms were, lethargy in 146 patients [56.2%]; increase in weight in 102 patients [39.2%] and menstrual irregularities in 90 patients [34.6%]

TSH level of < 10mlU/l [4-10] was seen in 177 patients [68.1%] and 83 patients [31.9%] had TSH > 10mU/l. Thyroxine was given to 183 [70.4%] of these patients. Common treatment indications were TSH of > 10, which was seen in 83 patients [31.9%], subfertility in 32 patients [12.3%], troublesome symptoms suggestive of hypothyroidism in 31 patients [11.9%] and high titers of antibodies in 23 patients [8.8%]

Conclusion: SCH is frequently seen in our population, with most patients complaining of lethargy. The most common treatment indications were a TSH > 10mlU/l, whereas troublesome symptoms of hypothyroidism and subfertility were the common treatment indications in patients who had a TSH of < 10mlU/l

Clinical spectrum of disorders of sexual differentiation

Objective: To describe the mode of presentation and causes of the disorders of sexual differentiation in patients presenting in the Endocrine Clinic. Study Design: Observational study. Place and Duration of Study: The Endocrine and Diabetes Unit of Jinnah Postgraduate Medical Centre [JPMC], Karachi, from July 2012 to July 2014

Methodology: Patients with phenotypic, psychosocial gender confusion or absence of gender appropriate secondary sexual maturation were enrolled in the study. Patients having chronic systemic disease, as cause of delayed puberty, were excluded from the study. SPSS 13 was used to evaluate the data

Results: A total of 48 patients registered in the study with mean age of 19.9 +/- 8 years. Female gender was assigned to 28 [58.3%] of which 8 [28.57%] had genital ambiguity. Male gender was assigned to 20 [41.66%] patients at the time of birth and 7 [35%] of them had ambiguous genitalia. Karyotyping could be done in 36 [75%] patients of which 17 [47.2%] were females and 19 [52.7%] were males. Karyotypic gender of the 19 [48.57%] male patients was 46 XX, 46 XY and 47 XXY; in 4 [21.05%], 5 [26.3%] and 10 [52.6%] patients, respectively with 9 Klinfelter syndrome. Karyotypic gender of 17 [47.42%] female patients were 46 XX, 46 XY and 45 X0; in 5 [29.4%], 3 [17.64%] and 9 [52.9%] patients, respectively

Conclusion: Disorder of sexual development constitutes a small but difficult area of endocrinology with disastrous consequences, especially if assigned wrong sex at birth. Mode of presentation of these cases was diverse ranging from delayed puberty, to gender confusion, to pregnancy in a male. Eventually in an adult patient assignment or reassignment of gender identity was primarily the patient's prerogative

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

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.

Magnetic Resonance Spectroscopy: Novel Non-invasive Technique for Diagnosing Brain Tumors

Objective: To determine the accuracy of MR Spectroscopy [MRS] in diagnosing brain tumors

Study Design: Analytical study

Place and Duration of Study: Neurosurgery Department, Jinnah Postgraduate Medical Centre, Karachi, from November 2010 to April 2011

Methodology: Fifty cases with brain tumors, who presented to Neurosurgery Department of Jinnah Postgraduate Medical Centre, Karachi, during the study period, were included in the study. All patients underwent MRS and later brain. Those with recurrent disease were excluded. Data was collected with the help of proforma. Data was analyzed using SPSS version 16. Comparison of MRS findings and biopsy diagnosis was done. Sensitivity, specificity, negative and positive predictive values [NPV and PPV] were determined keeping histopathology as the gold standard

Results: Out of the 50 patients, there were 20 [40%] females and 30 [60%] males with mean age of 37 +/- 13.24 years. The commonest presenting complaint was headache [76%] followed by weakness [62%] and seizures [30%]. MRI had diagnosed 27 [51%] as neoplastic lesion. Spectroscopy reported 44 [88%] as neoplasms, while on histopathology, 42 [84%] were confirmed to have neoplasm. The accuracy of MRS was 94%, with 97.6% sensitivity, 71.42% specificity, 95.45% PPV and 83.3% NPV

Conclusion: Magnetic resonance spectroscopy can readily help in differentiating neoplasm from non-neoplastic brain tumors, thus an invasive brain biopsy procedure can be avoided

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

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

Anterior decompression and fixation with webb-morley procedure in dorsolumbar spinal injury

To evaluate the neurological outcome of anterior decompression and fixation with Webb-Morley procedure in dorsolumbar spinal injuries. A case series study. The Neurosurgery Department, Jinnah Postgraduate Medical Centre, Karachi, from May 2008 to July 2010. Patients with post-traumatic unstable dorsolumbar spine having compression of the spinal cord with bony fragments of the fractured vertebra were included in the study. Patients below the age of 15 years and patients with bed sores and unfit for anaesthesia were excluded. Plain X-rays and magnetic resonance imaging [MRI] were done. All patients were treated for dorsolumbar fractures by anterior decompression and fixation with Webb-Morley procedure. All patients were assessed clinically by the Frankel's grading before and after surgery. Among 60 patients, 41 were males and 19 were females. Mean age was 37.2 +/- 4 years. Major cause of trauma was road traffic accident. The commonest level of the fracture was at the dorsolumbar junction i.e. 71.66% [n = 43]. About 19 [31.66%] patients improved to the Frankel's grade-E, while 41.66% [n = 25] improved to grade-D after surgery. There was no postoperative mortality. According to the current study, anterior decompression and fixation with Webb-Morley procedure is an effective and safe approach. Those patients who had complete motor deficit showed no improvement in power but those who had partial motor deficit, had excellent improvement

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

Outcome of cloward technique in cervical disc prolapse

To determine the association of pre-operative assessment of MRI findings, neurological status and symptoms with postoperative Cloward surgical outcome in cervical disc prolapse. Descriptive study. The Neurosurgery Department of Jinnah Postgraduate Medical Centre [JPMC], Karachi, from May 2008 to May 2009. Patients presenting with neck pain, brachialgia, limb weakness and spasticity were clinically examined for pre-operative neurological status of power, reflexes and sensation. The exclusion criteria were, cervical disc prolapsed patients, planned for smith-Robinson and micro-discectomy, traumatic cervical disc prolapse and cervical spondylosis. Neuroradiological investigations included cervical spine X-rays and MRI. All patients were surgically treated for cervical prolapsed intervertebral disc with anterior cervical discectomy and interbody fusion with Cloward technique. Postoperative neck immobilization was done with cervical collar for 7-8 weeks. Drain was removed on first postoperative day while check plain cervical X-rays were taken on third day. Results were analysed using chi-squre test with significance at p < 0.05. There were 30 patients including, 27 [90%] males and 03 [10%] females with mean age of 44.3 years. The commonest symptom was neck pain. The duration of symptoms ranges from 2 to 6 months. On MRI, prevalent levels of cervical disc prolapse were C 5-6 [43.3%] and C 6-7 [23.3%]; 26 [86.6%] patients had disc herniation causing thecal effacement with cord compression and 04 [13.3%] patients showed ischemia of cord. Single-level Cloward surgery done in 26 [86.3%] patients while two-level Cloward surgery performed in 04 [13.3%] only. About 83.3% patients improved and 13.3% did not while 01 patient was re-operated. No complications and mortality was related to the surgical procedure. Statistically different variables identified, related to outcome were pre-operative neurological status [p=0.001] and spinal cord involvement on MRI [p=0.001]. Cloward technique for cervical disc prolase was simple and safe surgical procedure with favourable results and few complications; 100% fusion occurred after Cloward surgery, even without instrumentation. Outcome was significantly affected by pre-operative neurological status and cord involvement

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

Correlation between clinical features and magnetic resonance imaging findings in patients with lumbar disc herniation

To find out the correlation of clinical features and magnetic resonance imaging [MRI] findings in determining the level of lumbar disc herniation. It was an analytic study, which was conducted in the department of Neurosurgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad, from 1st May 2002 to 1st March 2003. The total number of patients with prolapsed intervertebral disc, selected for this study was fifty. The clinical level of disc herniation was determined and was correlated with MRI findings. For data analysis, SPSS 10 soft ware was used. In 29 [58%] patients there was right sciatica, while eighteen [36%] had bilateral sciatica. Straight leg raising test was positive in 47 [94%] patients. On MRI, 48 [96%] cases had prolapsed intervertebral discs [PIVD] at L4-L5 and L5-S1 levels and 2 [4%] patients had L3-4 disc herniation. Thirty-eight patients had posterolateral disc herniation and 12 patients had central disc herniation. At L4-L5 level, the sensitivity, specificity, positive predictive value and negative predictive value of all clinical features was 92%, 96%, 95.85 and 88.46% respectively. The chi square value for L4-L5 and L5-S1 was 38.78 [P=0.000] and 22.12 [P=0.000] respectively, while for multiple level disc herniation, it was 3.42 [P=0.064]. Majority of PIVD lie in lower lumbar region. There is excellent correlation between the clinical features and MRI findings in the diagnosis of single level disc herniation but no correlation occurs in case of multiple level disc herniations

Career planning by the doctors in NWFP

To determine the extent to which a doctor in NWFP has the knowledge and opportunity to plan his career at right time and reasonable cost. This prospective descriptive study was conducted at the Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar from August 2006 to January 2007. Relevant information's were recorded on a questionnaire prepared in accordance with the objectives of the study. This study comprised of 82 individuals who responded to the questionnaire, with age ranging from 25-35 years [mean age 28.13 years, SD +/- 2.8, median 30 years]. Out of 82 respondents, 25 [30.5%] had received some kind of orientation about career planning while 56 [68.3%] had received no orientation so far [one respondent did not answered this question]. Out of 82, sixty-two [75.6%] were either self motivated to attempt a postgraduate exam or were guided by their teachers. In terms of time lost, 29 [35.4%] replied that they had wasted their time in thinking/choosing, while 13 [15.8%] pointed out to have wasted additional time in switching over their career from one field to another. Similarly, in terms of finance, 07 [8.07%] responded to have suffered financially. In NWFP due attention has not been paid to career planning and even the well educated class [doctors] are wasting their precious time and finances due to lack of guidance in career planning field

Role of cerebrospinal fluid diversion in posterior fossa tumor surgery

To assess the role of cerebrospinal fluid diversion in posterior fossa tumor surgery. Design: Descriptive study. Place and Duration of Study: This study was conducted at the Department of Neurosurgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad from February 2000 to July 2002 over a period of two and-a-half years. Subjects and Clinical, radiological and operative records of the patients who were operated for posterior fossa tumors were studied. Absolute and relative frequencies of the patients who were managed with external ventricular drainage [EVD] or ventriculoperitoneal shunt [VPS] were determined. Mean age and male to female ratio were also noted. There were 48 patients who were operated for posterior fossa tumors. Mean age was 23 years. Male to female ratio was 1.2:1. VPS was done in 14 patients [29%] pre-operatively, in one patient [2%] per-operatively and in 2 patients [4%] postoperatively. EVD was done in 33 patients out of whom 2 patients were shunted post-operatively. Sixty-five% of the patients remained shunt-free. Although management of hydrocephalus secondary to posterior fossa tumors is controversial, majority of the patients need temporary cerebrospinal fluid diversion