7-Month-Old Infant with Cushing's Disease

Cushing's disease in children is not rare but in infants it is quite rare and an important medical condition needing proper line of investigations and management options. Craniopharyngioma as a cause of Cushing's disease is well reported and practical inference of the condition is of clinical importance. Craniopharyngioma generally affects children at 5 - 10 years of age and is rarely seen in infancy. It usually manifests as endocrinological deficits such as short stature, delayed puberty, and obesity. We report the case of a 7 months old infant who presented with obesity and Cushing's disease associated with Craniopharyngioma

Surgical treatment of upper cervical spine injuries [C1-C2]: experience in 26 patients

To describe the spectrum of operations in unstable upper cervical spinal injuries in [atlanto-axial] region at our unit. A cross-sectional study. Spine Unit, Department of Orthopedics, Combined Military Hospital [CMH], Rawalpindi from Jan 2001 to Dec 2008. Frequency of different kind of operations in 26 patients operated for upper cervical spinal injuries was reviewed. A performa was made for each patient and records were kept in a custom built Microsoft access database. Average age of patients studied was 27 years with male pre dominance. Total 12[46%] patients had Atlanto-axial instability, 8[31%] had Hangman's fracture and 6[23%] patients had odontoid peg fracture. While 11[42%] patients had no neurological deficit according to American spinal injury association impairment scale [AIS-E] and 15[58%] had partial neurological deficit. The patients were divided into three groups. Group A had odontoid peg fracture, Group B had atlanto-axial instability and Group C had Hangman's fracture. The spine was approached posteriorly in 19[73%] cases and anteriorly in 7[27%]. Pedicle screw fixation was done in 6[23%] patients, odontoid peg screw fixation in 6[23%], Gallie's fusion in 5[19%], occipito-cervical fusion in 4[15%], posterior transarticular fixation in 3[12%], anterior transarticular fixation and decompression in others, 9[60%] patients improved neurologically postoperatively and there was no deterioration of neurological status. Nonunion in two [8%] cases and implant failure in one [4%] were complications. Upper cervical injuries [C1-C2] are rare and their management is complex, necessitating lot of experience for their management. Early diagnosis and appropriate treatment is essential for good outcome. Each injury has to be managed at its own merit and a single operation may not be appropriate in all situations. General guidelines can be drawn from our study for the management of these cases on modern lines

Surgical treatment in lumbar spondylolisthesis: experience with 45 patients

Spondylolithesis is forward slipping of upper vertebra in relation to its lower one, which at times requires surgery. The objective of present study is to document the outcome of surgical treatment in spondylolisthesis of lumbosacral region. We reviewed outcome of surgery in 45 patients with spondylolisthesis. Improvement in pain intensity, neurological status and union achieved after surgery was studied. All patients requiring surgical treatment were included in the study. The patients were operated by single spine surgeon. A Performa was made for each patient and records were kept in a custom built Microsoft access database. Majority of our patient were in 4[th] and 5[th] decade with some male domination. Pain was main indication for surgery which was excruciating in 6, severe in 33, and moderate in 6 cases. The neurological status was normal in 34 cases while 11 patients had some deficit. L5-S1 was affected in 26, L4-L5 in 13 and multi or high level was found in rest of cases. Slip grade was measured with Meyerding grades, 18 had grade II, 15 had I, 9 had III and 3 had IV spondylolisthesis. Posterior lumbar inter body fusion [PLIF] was done in 24 patients, posterolateral, transforaminal lumbar inter body and anterior inter body fusion in others. Translaminar screw fixation, transpedicular transdiscal transcorporial and Delta fixation in some cases. Pedicle screw fixation was done in most cases, AO fixator internae and 4.5 mm screw in others. Average follow up was 2 years and 5 months, max 5 years and minimum 6 months. Pain relief was achieved in 82%, neurological improvement 60% and union in 91% cases. There was no deterioration of neurological status, two implant failure and one wound infection. Surgical procedure for Spondylolisthesis must be individualised. Young patients with spondylolysis can be treated with osteosynthesis and sparing of motion segment. PLIF provides satisfactory results in majority of low to moderate cases with some reduction. Transpedicular transdiscal transcorprial and delta fixation is good procedure for severe slips in adult.

Pheochromocytoma: a rare cause of childhood hypertensive encephalopathy

Pheochromocytomas are rare neuroendocrine tumours of chromaffin tissues. They are catecholamine secreting tumours which cause severe hypertension and other systemic disturbances. Of all the causes of childhood hypertension, pheochromocytoma constitutes less than 1%. We report the case of a 12 years old child who presented with hypertensive encephalopathy, confirmed histologically to be secondary to pheochromocytoma, and cured with meticulous critical care and surgical resection

Pin tract care in locally made external fixators: a new treatment protocol

To calculate the frequency of pin tract infection in locally made external fixator pins using our set protocol. Descriptive study. This study was conducted in Combined Military Hospital Sialkot and Combined Military Hospital Quetta over a period of 3 years and 6 months from May 2003 to November 2006. A total of 451 Pin tracts from 50 external fixator were studied in forty nine patients. Inclusion criteria was all external fixator pins to the limbs excluding the skeletal tractions. Local Shanz screws and Kirschner wires of two different sizes were studied. The protocol was twice a day cleaning of pin tracts with povidone iodine [pyodine], twice a week soap and water bath with soft brushing where main wound was healed. At the time of removal of fixator the pin tracts were curetted and washed with 0.9% normal saline. Average age of the patients was 32.91 years most of them were young males, 23 [47%] in 3rd and 4th decade. Only 4 [8.1%] were females. Tibia was most commonly involved bone in 38 patients [77.5%], while femur in 6 patients [12.2%] and foot and upper limb were affected in only a few cases. Road traffic accident was most common etiology in 33 [67.34%] patients either presenting as open fractures or infected nonunion. Out of 451 pin tracts, 233 [51.66%] were locally made shanz screw half pins and 218 [48.33%] were locally made Kirschner wires full pins. The mean fixator time was about 17 weeks with maximum 48 weeks and minimum 7 weeks. Maximum follow up was 12 months minimum follow up was 3 months after removal of fixator. We had 25 [10.72%] minor pin tract infections of shanz screws, 5 [2.29%] minor pin tract infections of kirschner wires. We had to remove and change 3 [1.28%] Shanz pins. We had no true complication. Standardizing a set protocol for pin tract care irrespective of wound type has shown excellent results with minimum morbidity. This simple method not requiring any expensive equipment can be tried in any hospital to avoid pin sores

Sonographic evaluation of the triangular cord sign in the diagnosis of biliary atresia, confirmed with needle liver biopsy

Neonatal cholestasis continues to present a diagnostic challenge for pediatric surgeons. Various diagnostic protocols are available, often involving invasive procedures which are generally not available in the district general hospitals. The objective of this study is to evaluate the role of Triangular Cord sign [TC sign] on ultrasound for the prompt and easy diagnosis of biliary atresia in infants. A prospective study was planned. Patients with positive TC sign underwent needle liver biopsy for confirmation. Infants with neonatal cholestasis were referred from the gastroenterology department. Abdominal ultrasound was performed with 3-6MHz convex and 6-10MHz linear transducers on Core Vision, Toshiba by a single paediatric radiologist and results were correlated with needle biopsy of the liver interpreted by the histopathologist. Thirty nine Infants with cholestatic jaundice underwent ultrasound and biopsy. Twenty patients were diagnosed on ultrasound as biliary atresia on the basis of positive triangular cord sign and 18 of them were confirmed on biopsy

Histiocytosis in children: Five years experience at a tertiary care hospital

Histocytosis is a diverse group of illness of monocyte- macrophage cell lineage. Diagnostic criteria and management protocols are not precisely defined due to cases. Study was conducted to review the clinical features at admission and outcome of histiocytosis following chemotherapy [DALHAX 83 protocol was used]. It was a retrospective study, carried out from March 2000 to February 2005, at department of hematology- oncology, The Children's Hospital and the Institute of Child Health, Lahore. From 01-03-2000 to 28-02-2005, total 36 cases with histocytosis disorders were admitted. It comprises 2% of total admissions, class 1 langerhan cell disease was the most common [24/36], followed by class II [8/36] and class III [4/36] cases among this group of illness. Fever and hepatosplenomegaly was present in all classes. Soft tissue swelling, jaundice and lymphadneopathy were also seen in class I, II and III histiocytosis respectively. Nineteen patients died/ left treatment and absconded with incomplete treatment. Seventeen patients responded to chemotherapy again. Histiocytosis class I is a chemosensitive disease. If the functional deterioration of the involved organ has not set in, class I disease has good prognosis

Spinal surgery in earthquake victims

Objective of present paper is to document the operations performed in earthquake spinal injury patients and to analyze the results of surgery. This is a quasi-experimental study. This study was conducted at the department of Orthopaedic and Spinal surgery at Combined Military Hospital [CMH], Rawalpindi. Study started after earthquake in Pakistan on 8[th] of October 2005 and ended in August 2006. 250 patients with spinal injury were admitted at the three main army hospitals at Rawalpindi [CMH, MH and AFIRM] after earthquake on 8[th] October 2005. Out of these, 110 patients underwent 120 major spinal operations. 12 patients were received from other units for revision surgery. 75% of the patients were civilians and 25% were army personnel and their families. Average age was 28 years and range was 8-65 years. 56% patients were females and 44% were males. 46% patients had complete neurological deficit and 54% had incomplete neurological deficit. Most common associated injuries were fractures of tibia and fibula. Most common level of injury was at T12/L1 [55%]. After surgery almost all patients had rehabilitation at AFIRM. Post-operatively excellent [>75%] or good [50-75%] correction of deformity was achieved in 90% of patients. 92% patients had mild or no pain, post-operatively. Neurological improvement was seen in all patients with incomplete deficit except four. Some patients with complete deficit also showed improvement. Overall there was 1.5 AIS improvement per patient. At last follow up 46% patients were walking independently and 51% were independent in wheel chair. Spinal surgery in patients with unstable spines after major disaster should be carried out by properly trained surgeons as soon as possible and in a setup where facilities for proper rehabilitation are available as it carries best prognosis for these high risk and at times paralyzed patients