Positive CT brain during early postoperative period in head injury patients: impact on clinical course and outcome

Objectives: To assess the impact of positive postoperative CT head during the initial 72 hours on overall clinical course and outcome

Methodology: 157 patients of head trauma who underwent cranial surgery were prospectively included. All patients underwent a repeat head CT during the initial 72 hours or as was indicated by neurological status of the patient. Data was collected about patient demographics, initial CT diagnosis, repeat CT findings, re-operation if performed, GCS at discharge, mortality and outcome in terms of GOS. Data was analysed for impact of positive finding in postoperative CT head and its impact on clinical course and outcome

Results: The overall mean age was 34.25 +/-11.59 years with a mean arrival GCS of 9.2 +/-2.32. The mean time to first postoperative CT was 21.45 +/-9.83 hours. The postoperative CT scan was positive in 29 [18.5%] patients in which 16 [10.2%] cases required re-intervention. Overall mortality was 19 [12.1%], of which 9 [44.1%] had a positive post-operative CT scan and 4 [21.1%] of them underwent a repeat intervention. 2.3% of patients with negative CT were re-operated while 44.8% were re-operated in the positive CT [p <0.0001]. Similarly, mortality was 7.8% in the negative CT group while it was 31.0% in the positive CT group [p <0.0001]

Conclusions: Positive follow-up CT scan during early post-operative period can affect significantly the clinical course and neurological outcome of patients

Role of anterior decompression with internal fixation in dorsal spine tuberculosis

To assess efficacy of anterior decompression and internal fixation using mesh cage and rod with screws in patients with dorsal spine tuberculosis This observational study was conducted in the Department of Neurosurgery Lady Reading Hospital Peshawar from July 2010 to June 2012 [2 years]. There were 38 patients with dorsal spine tuberculosis who underwent anterior decompression and fusion using anterior spinal instrumentation and allograft replacement. We included those patients in our study, who undergone anterior decompression with internal fixation for dorsal spine tuberculosis, of both genders irrespective of their age. We excluded those patients who were unfit for surgery, treated conservatively, involved spine other than dorsal spine or undergone procedure other than anterior approach for Carrie's spine. Clinical outcome of the patients was assessed using the frankle grade. The patients were observed for post-operative complications, neurological improvement and bony fusion. We had total of 38 patients who undergone the procedure in whom23 [60.5%] were males and 15 [39.5%] females with male / female ratio of 1.5: 1. Their age ranged from 4-70 years [mean 37years]. The most common level involved were between D5-D12 for which thoracotomy was needed. Preoperative neurodeficit was observed in 76.3% patients of whom 89.7% showed improvement after surgery. Our patients had 7.9% complications after surgery. We had wound infection in 5.3% and dyspnea in 2.6% cases. There were no graft related complications and bony fusion was observed in all the patients. It is concluded from our study that anterior decompression with internal fixation using cage and rod with screws is an effective procedure in dorsal spine tuberculosis. It has few complications and yields good results

Frequency of causes of ventriculo-peritoneal shunt failure in hydrocephalus patients

To analyze ventriculo-peritoneal shunt [VP shunt] failure cases in hydrocephalic patients, in a tertiary care hospital. This descriptive study was carried out in the Department of Neurosurgery Lady Reading Hospital Peshawar, from June 2009 to May 2010 [one year].The medical record of all cases operated in last one year was checked from record room. Documentation was done according to proforma designed indicating age, sex, clinical features, investigations with findings on X-rays, CT and MRI and per operative findings. Complications related to upper end, lower end and shunt track were noted. Data was analyzed to assess the causes for shunt failure in hydrocephalus patients. A total of 56 patients were included in this study. There were 43 children and 13 adults. Among children, 26 were males and 17 were females while in adults, 5 were males and 8 were females. Out of these, 28 patients were having blocked shunt, 20 cases with infected shunt, 6 patients had eroded and 2 patients displaced shunt. Although shunt surgery is a common procedure performed for hydrocephalus, different complications were associated in our study where shunt failure was mainly due to shunt dysfunction, infection or breakage of shunt system. Complications were more with upper end. Infection was common in pediatric age group

Influence on visual deficit after transsphenoidal hypophysectomy for pituitary adenomas

Background: Transsphenoidal surgical exision of pituitary tumor in widely used route

Objective: To determine the effects on visual symptoms after transsphenoidal hypophysectomy for pituitary adenomas

Patients and Methods: This retrospective study was conducted in the department of neurosurgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar. All patients from January 2006 to January 2011, who underwent transsphenoidal surgery for pituitary adenomas, were included for visual deterioration

Results: During the five years time a total of 65 patients were operated for transsphenoidal adenomas. Four patients were excluded due to various reasons. There were 44 [72.13%] male and 17 [27.87%] female patients. The age ranged from 31 years to 62 years. The mean age was 44 years. There was improvement in visual symptoms in 39 [63.93%] patients immediately after surgery, 13 [21.31%] patients showed improvement in four weeks time, while there was no improvement in 9 [14.75%] patients

Conclusion: The improvement in visual symptoms occurs in majority of the patients after transsphenoidal hypophysectomy. There are several factors which influence the outcome, like duration and size of the lesion

Histological findings of posterior fossa tumors in children

To find out different histopathological types of posterior fossa tumors in children. This Descriptive study was carried out in Department of Neuro surgery Govt. Lady Reading Hospital Peshawar from June 2003 to May 2008, All patients with posterior fossa tumors under 14 years were included in the study. Patient with brainstem glioma, posterior fossa abscesses and pineal tumors were excluded. A total of 117 patients were included. There were 80 male and 37 female with sex ratio of 2.1:1 with age range from 6 months to 14 years with mean age of 8.9 years and SD + 5.4. Computerized Axial Tomography / Magnetic Resonance Imaging of the brain were done for establishing diagnosis. Different surgical procedures for tumor removal were performed and specimen was sent for histopathological study in all operative cases. Out of 117 patients Medulloblastoma was seen in 38 [32.7%], Ependymoma in 23 [19.65%] Astrocystoma in 25 [21.36%], Hemangioblastoma in 19 [16.23%] Tuberculoma in 4 [3.41%] Meningioma in 2 [1.7%] and dermoid and epidermoid cyst in 3 cases each [2.56%]. Medulloblastoma was seen commonly between 6-10 years in 22 [18.8%] patients. Astrocystoma between 6 -10 years in 12[10.25%] patients. Ependymoma is common below 5 years in 17[14.5%] patients. Hemangioblastoma between 6-10 years in 15 [12.82%] patients, tuberculoma in 3[2.56%] patients in 6 -10 years of age. Medulloblastoma and Pilocytic Astrocystoma and Hemangioblastoma are common tumors between 6-10 years of age and Ependymoma is common below 5 years. Tuberculoma is also tumor mimicking condition occurring in posterior fossa

Per-operative findings of blocked ventriculoperitoneal shunt: a study of 72 cases

Most patients with hydrocephalus are treated with ventriculo-peritoneal [VP] shunt placement; however, malfunction is common and is usually caused by mechanical failure. The aim of this study was to evaluate the per-operative findings accompanying presumed VP shunt malfunction. This is a descriptive study of 72 patients operated for shunt malfunction in the Department of Neurosurgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from January to December 2008. Presenting symptoms and signs, clinical shunt function, operative findings and outcome were recorded. Common presenting features were vomiting, irritability and general toxic look of patients. Male to female ratio was 3:1. Upper end block was observed in 39 patients while lower end and reservoir block was noted in 13 and 2 patients respectively. Choroids plexus was found in 29.2% of cases with upper end block, shunt revision was performed in most of cases [80.6%]. The importance of clinical features cannot be overlooked in a patient with shunt malfunction. Upper end block due to choroids plexus is common operative finding

Surgical outcome of transpedicular fixation in thoracolumber fractures

Development of transpedicular screw fixation techniques and instrumentation systems has brought short-segment instrumentation [fixation of one normal vertebra above and below an injured segment] into general clinical practice. The purpose of this study is to report the surgical outcome of thoracolumber fractures treated with short-segment pedicle instrumentation. A retrospective review of all surgically managed thoracolumbar fractures during two years was performed. The 84 surgically managed patients were instrumented by the short-segment technique. Patients charts, operation notes, preoperative and postoperative radiographs, computed tomographic scans, magnetic resonance imaging [MRI] was done. Neurological findings [Frankel functional classification], and follow-up records up to 6 months were reviewed. Transpedicular fixation was performed in 84 cases including 52 male and 32 female with male to female ratio 1.6:1. Mean +/- SD of age was 40 +/- 13.75 years [range15-60]. The level of injuries was different in different age groups. Outcome was assessed on Frankle grading. No patient showed an increase in neurological deficit. Most of the patients showed improvement to the next grade. Screw breakage occurred in 8 cases, bed sores in 16 cases and deep vein thrombosis in 3 cases. Misplaced screw in 5 cases. Eight cases got wound infection. Although long term follow-up evaluation needs to verified, the short term follow-up results suggest a favourable outcome for short-segment instrumentation

Significance of trigger point in trigeminal neuralgia

To know the significance of trigger point as an indicator of aberrant vascular loop in patients with trigeminal neuralgia. Material and This study was performed in the department of neurosurgery Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from May 2003 to April 2006. Patients with clinical history of trigeminal neuralgia were admitted for micro vascular decompression. Detailed clinical history, along with clinical findings particularly side and site of trigger point of trigeminal pain were documented. Imaging studies like CT, MRI were done in these cases and per-operative findings were documented after surgical procedure. Forty-three patients with trigeminal neuralgia were operated for micro vascular decompression during the study period. There were 24 [55.8%] males and 19 [44.2%] females with ratio of 1.2: 1, and a mean age of 53 years. Duration of symptoms was from 3 to 7 years. A total of 43 cases of trigeminal neuralgia were recorded. Right side was involved in 19 and left side in 24 cases. Peri-oral and peri-nasal trigger point was observed in 39 [90.7%] cases during examination while offending arterial loop was seen in 35 [81.4%] cases per-operatively, thick arachnoid adhesion in 4 [9.3%] cases and veins in 4 [9.3%] cases. Trigger point during clinical examination indicated the presence of offending arterial loops in patients with trigeminal neuralgia

Acute extradural haematoma: factors affecting the outcome

The objective of the present study was to determine the factors that affect the outcome in the management of acute extradural haematoma. Material and The study was carried out at the Department of Neurosurgery, PGMI Hayatabad Medical Complex Peshawar, from 1st January 2000 to 31st December 2001. The clinical record of patients who were operated for acute extradural haematoma in the Neurosurgical Unit was reviewed. Their clinical condition, Glasgow coma score [GCS], duration and mode of trauma at the time of presentation were noted. The CT Scan findings, and the surgical procedure done, were analyzed. The postoperative outcome was assessed on the basis of Glasgow coma score. In this study 108 patients operated for acute extradural haematoma were selected. The ages ranged from 8 months to 65 years with male to female ratio of 5:1. Out of these patients, 26 [24%] were less than 15 years, 38 [35.1%] were between 16 and 30 years, 32 [29.6%] between 31 and 45 years. A satisfactory out come was achieved in 74 [69%] cases that presented within 12 hours as compared to those who presented late. Patient's age less than 45 years had better outcome as compared to those with more than 45 years of age. Mortality rate was 8% [n=7]. Timely surgery in patients who are in younger age group has better out come. The size of the haematoma and mode of trauma are also important factors that affect the outcome

Surgical management of trigeminal neuralgia by microvascular decompression

To find out the of Microvascular Decompression for trigeminal Neuralgia, not responding to conservative treatment. Material and Between January 1998 and December 2001. Fifty patients underwent Microvascular decompression for trigeminal neuralgia in the Department of Neurosurgery, Hayatabad Medical Complex, Peshawar. There were 36[72%] male and 14[28%] female patients. Among them 48[96%] were unilateral cases of trigeminal neuralgia. Right side was involved in 18[36%] and left side in 32[64%]. All patients underwent Microvascular Decompression. During surgery, Superior Cerebellar Artery was found to be the offending vessel in 27[54%], Anterior Inferior Cerebellar Artery in 10[20%], Posterior Inferior Cerebellar Artery in 01[02%], Unnamed vessel in 04[08%], Vein in 03[06%]. In 03[06%] no vascular compression could be detected during the surgery. During the follow-up period 40[80%] patients had excellent Results:. Good were achieved in 06[12%] and no response in 04[08%] of patients. After surgery 04[08%] patients developed transient vomiting and vertigo, 01[02%] patient developed wound infection and 01[02%] had Cerebrospinal Fluid Leak from wound. Cerebrospinal Fluid Rinorrhoea occurred in 02[04%] patients. One patient [02%] developed permanent ipsilateral Facial nerve weakness. There was 01[02%] postoperative death. Trigeminal neuralgia is disease of different etiologies. Vascular compression of the trigeminal nerve roots at its entry into pons is one of the most accepted aetiology. Microvascular decompression has become one of the primary treatment of trigeminal neuralgia. We believe that in patients where medical treatment fail to respond, Microvascular decompression is the treatment of choice in trigeminal neuralgia