Radiological and clinical outcomes in patients undergoing anterior cervical discectomy and fusion: comparing titanium and peek [polyetheretherketone] cages

Objectives: To study clinical and radiological outcomes in patients who had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK [polyetheretherketone] cages for cervical disc prolapse

Methods: This is a retrospective/non-randomized study which was conducted at the Combined Military Hospital Peshawar. Study interval was four years from 1st October, 2010 to 31st September, 2014. Total number of included patients were 149. All of the patients had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK [polyetheretherketone] cages. All of the patients had plain MRI cervical spine done for diagnosis of anterior cervical disc prolapse

Results: Most of the patients had stenosis at the C5 / C6 [PEEK cage group 63% and titanium cage group 47.6%] and C6 / C7 [PEEK cage group 15.38% and titanium cage group 19.04%] cervical level. Bi-level involvement was also seen. In the patients who complained of brachialgia, total resolution of symptoms was seen after the operation. Three [2.01%] of the patients in titanium cage group, who presented with axial neck pain, continued to complain of pain after the operation. Four [2.6%] of the patients in PEEK [polyetheretherketone] cage group and 2 [1.3%] in titanium cage group complained of pain at the donor site [iliac crest]. Fusion rate was 100% with both titanium and PEEK [polyetheretherketone] cages at one year

Conclusion: Results with titanium and PEEK [polyetheretherketone] cages are excellent. There was no significant difference in clinical and radiological outcome between two groups of patients [p > 0.05]. Fusion rate was 100% at one year with both cages

experience with ventriculoperitoneal shunting at keen’s point for hydrocephalus

Objective: This study was conducted to assess outcomes in patients with hydrocephalus who underwent ventriculoperitoneal shunting at Keen's point

Methods: This retrospective study was conducted in Combined Military Hospital [CMH] Peshawar. Time frame was four years from January 2011 to January 2015. The presenting complaints, clinical findings, investigations, treatment plans and surgical outcomes were noted. Ventriculo-Peritoneal [VP] shunting was done at Keen's point. The presence of shunt complications in the first week post-surgery was noted and at a three-month follow up in the outpatient department. General condition of the patient, shunt complications, presence of seizure and worsening of vision were noted

Results: Study included 143 patients, out of whom 46 were females and 95 were male patients. Most common causes of hydrocephalus were congenital [79]. Majority of adults had hydrocephalus due to central nervous system tumors while congenital hydrocephalus in children was most frequently due to aqueductal stenosis. Good clinical improvement was seen in 114 patients after shunt placement, satisfactory in 20 patients, 7 patients died while we observed no change in two patients

Conclusion: Our experience with VP shunting at Keen's point resulted in excellent outcomes. It can be used for the management of hydrocephalus both in pediatric as well as adult population

latissimus dorsi flap for the reconstruction of complex chest wall defects: is a polypropylene mesh and a flap enough?

Objective: To determine the outcomes of the use of the Latissimus Dorsi Flap for the Reconstruction of Complex Chest Wall Defects: Is a polypropylene mesh and a flap enough? Study Design: Descriptive case series. Place and Duration of Study: The study was conducted in the department of Plastic and Reconstructive Surgery Shifa International Hospital Islamabad, over a period of 5 years between Jan 2012 and Dec 2016

Material and Methods: All patients with chest wall defects, post tumor resection diagnosed on tissue biopsy, trauma, osteoradionecrosis and infection were included in this study. The chest wall was reconstructed with a polypropylene mesh and the latissimus dorsi flap. All the patients with tumors were discussed in multidisciplinary team meeting. Patients with post coronary artery bypass surgery wounds were excluded from this study. Demographic data including age, sex, histopathological diagnosis of disease and other outcomes were studied

Results: Total 22 patients were included in this study over a period of 05 years, 16 patients with tumors. Age range was 12 to 63 years. Mean follow up time was 3 years. Six patients developed postoperative complications: one patient had partial skin graft loss at the recipient site. Two patients developed partial wound dehiscence one at the donor area and other at the flap inset site. One patient had partial distal flap loss and graft loss at donor area. There was no mortality in our series

Conclusion: Our study revealed that the polypropylene mesh covered with the latissimus dorsi myocutaneous flap is adequate for skeletal stabilization of composite chest wall defects achieving satisfactory functional and aesthetic results

To determine the outcomes of free tissue transfer for large scalp and forehead defects reconstruction

Objective: To determine the outcomes of free tissue transfer for large scalp and forehead defects reconstruction. Study Design: A descriptive case series. Place and Duration of Study: The study was carried out at Plastic surgery department, Shifa International Hospital Islamabad, over a period of 5 years from Mar 2011 to Feb 2016

Material and Methods: All the patients who underwent scalp reconstruction for soft tissue or composite defects greater than 6 cm 2 during the period of 5 years were included in the series and were followed post operatively for 6 months. The patient's demographic data, medical history, surgical history, comorbidities, age, and gender were also analyzed. Indications for surgical intervention included cutaneous malignancy of the scalp, bony tumors, vascular lesions and traumatic tissue loss requiring reconstruction

Results: A total of 20 patients [60% female and 40% male] with mean age of 38.75 years [SD=14.44], who underwent a reconstructive surgery for scalp defect, were assessed. The scalp defect were secondary to tumor resection [n=10; 50%], post-traumatic wounds [n=5, 25%] and resection of vascular malformations [n=5, 25%]. Free flaps used for reconstruction were: Antero Lateral Thigh Free Flap [ALTF] [n=8; 40%], Radial Forearm Free Flap [RFFF] [n=6, 30%], free latissimus dorsi [n=4, 20%] and Transversus Abdominis muscle [TRAM] flap [n=2, 10%]

Conclusion: Scalp and forehead defects, if treated adequately, can heal with stable and aesthetically acceptable results and flap selection should be individualized according to the defects, patient's factors and availability of particular flap

Homozygous mutations in NTRK1 gene underlie congenital insensitivity to pain with anhidrosis in Pakistani families

Congenital insensitivity to pain with anhidrosis is a rare autosomal recessive disorder presenting with loss of pain sensation, thermal sensation defects, and self-mutilating behavior. In the present study, we recruited two consanguineous pedigree showing pain insensitivity symptoms from Pakistan for clinical and molecular investigations. In family A, one female patient displayed classical CIPA symptoms along with microcephaly and severe intellectual disability. During course of the disease, her right foot was amputated and had remarkable dental degeneration and teeth shedding. In family B, one boy presented with classical symptoms of congenital insensitivity to pain with anhidrosis. Blood was collected from both families for molecular studies. Sequencing with the Ilumina Trusight One Sequencing Panel covering 4813 OMIM genes revealed a known homozygous mutation c.2084C>T; p.P695L of NTRK1 in family A and a novel truncated mutation c.2025C>G; p.Y681X in family B. Protein modeling analysis of both mutations (p.P695L and p.Y681X) predicted loss of the rigidity in tyrosine kinase domain of NTRK1 that led to conformational changes as well as deleterious effect on protein function. The known mutation was reported more than a decade ago in a family from Northern Israel and other non-sense mutation is newly identified. It is interested that most of NTRK1 mutations are associated with this domain. This is first ever report of NTRK1 variants in congenital insensitivity to pain with anhidrosis patients from Pakistan.

Factors related to the use of internet for health care management among university students

To determine the frequency of using internet for diagnosis and treatment of medical conditions; to identify the most frequent [websites] resources used for selfdiagnosis and treatment of medical conditions; to assess the awareness of inaccuracy of information on internet for self-diagnosis of medical conditions A cross-sectional study was done including students in the GMU using validated self-administered questionnaire. The questionnaire includes in addition to socio-demography of participants, information about the use of internet for self health management, most common website searched, history of complication following the use and if they had verified the diagnosis with treating physician. Informed consent was taken from participants and the confidentiality of the participants was maintained. Data was analyzed using SPSS V.20 and Chi-Square test was done. The results showed that 93.6% of the participants were using internet for healthcare management and the main reason was the ease of accessing medical information online. In 75.9% of respondents who had used the internet for self-management, the diagnosis was verified with a doctor, and 49.7% of them found that it was inaccurate. 43% of the participants took medication listed online followed by their internet-based self-diagnosis. Specialized medical websites were the most credible source as 57.10% of the study sample using this successfully verified their diagnosis with a doctor. Most of the participants were using the internet for self-diagnosis and management and 49.7% of respondents found that the diagnosis was inaccurate after it had been verified by a doctor. Specialized medical websites were the most credible source. It was identified that students do realize how inaccurate the internet can be

Quality of life assessment in patients with locally advanced head and neck malignancy after ablative surgery and reconstruction with microvascular free flaps

To assess the improvement in Quality Of Life [QOL] after ablative surgery in locally advanced head and neck malignancies by microvascular free flaps reconstruction. Quasi-experimental. Department of Plastic Surgery, Combined Military Hospital, Rawalpindi, from September 2005 to February 2007 A total of 44 patients with locally advanced stage III and IV malignancy of head and neck were included in the study. All patients were treated with ablative surgery and reconstruction with microvascular free flaps. QOL was assessed by using a scoring questionnaire [including 5 parameters for extra oral cancers including physical and role function, body image, weight loss score and pain donor site morbidity; and an additional 5 parameters for intraoral tumours that included swallowing, speech, drooling of saliva and mouth opening]. A high score indicated a poor QOL. Patients were assessed pre-operatively and then at 2, 4 and 6 months postoperatively. Mean accumulative score and mean individual parameter scores for both extra- and intraoral tumours were significantly improved [p < 0.05]. Microvascular free flap reconstruction after ablative surgery in locally advanced head and neck malignancy had a profound impact on the improvement of QOL. There was an initial deterioration of physical scores postoperatively and postradiotherapy, followed by gradual improvement. By the end of 6 months, it surpassed the pre-operative QOL scores

Tuberculous tenosynovitis: a cause of carpal tunnel syndrome

To highlight the presentation of tuberculous tenosynovitis as Carpal Tunnel Syndrome [CTS]. A descriptive study conducted with purposive sampling on the patients presenting between April 2004 to January 2005 to the department of Plastic Surgery, CMH Rawalpindi, with the clinical picture of CTS. Symptoms and signs were recorded. The carpal tunnels were explored under nerve blocks. Where tenosynovitis was observed per-operatively, specimen of excised synovium were sent for histo-pathological examination, acid fast stains and bacterial cultures, to ascertain or rule out the presence of tuberculosis. A total of 53 patients predominantly males were included in the study. The median age was 43 years and average duration of symptoms was 9 months. Tenosynovitis was observed in three patients [6%] per-operatively, with histopathology suggestive of Tuberculous tenosynovitis. Point Prevalence of tuberculous tenosynovitis as a cause of CTS was 6%. These patients reported clinical improvement with anti-tuberculosis treatment. NCS/EMG co-related well with clinical relief. Tuberculous tenosynovitis is an uncommon cause of median nerve compression at the wrist. As symptoms are usually typical of CTS, diagnosis is frequently missed. Consideration of the possibility, examination of the opened canal at surgery and proper treatment can result in a successful outcome

Experience with lateral cheek rotation flap for the reconstruction of medial cheek soft tissue defects

To analyze the results of reconstruction in terms of complications, functional restoration and cosmetic restoration of lateral cheek rotation flap. A cross sectional study was conducted between April 2004 and January 2005. Patient's particulars and history were documented. The cause, whether trauma or tumor resection, and dimensions of the defects were recorded. All the patients underwent a "cheek rotation flap" procedure to reconstruct the defect. Post-operative complications like haematoma formation, infection and flap necrosis were noted. Results were assessed in terms of functional as well as aesthetic restoration. A total of 30 patients were included with a male to female ratio of 3:1 and an average age of 46 + 14.7. The majority of the defects [76%] were post tumour excision, while the rest [24%] followed trauma. The average defect diameter was 7.5 cms. There was no peri-operative mortality or total flap loss. There were three cases [10%] of transient facial nerve palsy who recovered spontaneously. The final reconstruction was deemed satisfactory in terms of functional and cosmetic restoration in the majority of cases [93%]. Our results with the lateral cheek rotation flap to reconstruct the defects involving medial cheek have prompted us to recommend it as a first line reconstructive option for many varieties of defects in this area

Skin sparing mastectomy and immediate breast reconstruction

To evaluate skin sparing mastectomy[SSM] and immediate breast reconstruction[IBR] in terms of the survival, chances of recurrence, aesthetic restoration and prevention of psychosocial problems. An interventional study. The Department of Plastic and Reconstructive Surgery, CMH, Rawalpindi from November 1998 to November 2003. Twenty-eight patients of breast cancer, included in the study, were discussed in a Multidisciplinary Breast Clinic. Detailed metastatic work-up was performed. In all patients SSM with en-bloc level II axillary clearance and IBR was done. The patients' age ranged between 25-46 years. Two patients [7%] were nullipara. Tumor size was T1 in 10 [36%] and T2 in 18 patients [64%]. In all the patients a circum-areolar incision was used. A contralateral uni-pedicled TRAM flap was used in 24 [86%] and latissimus dorsi flap in 4 patients [14%]. All the flaps survived completely. There was marginal necrosis of native skin flaps in 03 [10.5%], infection in 03 [10.5%], axillary seroma in 03 [10.5%] and abdominal seroma in 01 patient [3.5%]. As late complication 5 patients [19%] developed fat necrosis. Adjuvant chemotherapy was given in 6 [21%] and adjuvant radiotherapy in 4 patients [14%]. No recurrence encountered in maximum follow-up. We found an excellent aesthetic restoration in 23 [82%], good in 1 [3.5%] and fair in 4 patients [14%]. SSM for patients with early breast cancer is an oncologically safe procedure. IBR can greatly reduce the psychological trauma associated with breast loss including diminished feelings of feminity, decreased libido, social behavior, sense of mutilation and depression

comparison of two fasciocutaneous flaps in the reconstruction of defects of the weight-bearing heel

To compare the indications, ease of elevation, operative time, complications and durability of two fasciocutaneous flaps i.e. sensate medial plantar artery flap and distally based sural artery neurocutaneous flap, used for the coverage of weight bearing heel in young ambulant adults. Design: A comparative study. Place and duration of study: CMH Rawalpindi and PIMS Islamabad during the period from May 1995 to April 2002. Patients and All the patients fulfilling the inclusion criteria discussed later in the text were divided into two groups. Twenty patients underwent a medial plantar artery flap [MPAF] while 30 had their defects reconstructed by a sural artery neurocutaneous flap [SANF]. The mode of presentation was noted in each case with a special note of the etiology. Postoperatively the patients were followed-up to evaluate any early or long-term complications. The MPAF group consisted of 20 patients including 16 males and 4 females with a mean age of 28 years [range 22 to 37 years]. The SANF group consisted of 30 patients including 29 males and only one female with a mean age of 30 years [range 23-38 years]. In both groups a majority of patients presented with a history of road traffic accidents and was managed by delayed primary procedure. The duration of the operation was considerably less in SANF coverage i.e., 50-100 minutes compared to 120-190 minutes for the MPAF. Flap survival was 100% in both the groups. The postoperative complications were more in patients who underwent SANF. Complete weight-bearing was started at 6 weeks in medial plantar artery flap whereas the same started 6-8 weeks in sural artery neurocutaneous flap. Average time for return to work was 8 weeks in medial plantar artery flap but it was double [12 weeks] in sural artery neurocutaneous flap. The medial plantar artery flap provides sensate and the same quality skin cover to the weight-bearing heel as compared to the distally based sural artery neurocutaneous artery flap. The medial plantar artery flap procedure is longer to perform but allows early weight-bearing with less complications than the distally based sural artery neurocutaneous flap

Reconstruction of lip defects with the Karapandzic technique

To study the use and effects of Karapandzic technique of lip reconstruction by long-term assessment. Design: A descriptive study. Place and Duration of Study: CMH Rawalpindi from January 1994 to January 2002. Subjects and Thirty seven consecutive patients who underwent Karapandzic technique of lip reconstructon with a minimum follow-up period of two years have been included. The variables assessed were hemorrhage, wound infection, flap necrosis, microstomia, reconstruction time, hospital stay and dynamic lip functions. Results drawn were analyzed. A total of 37 patients were included in the study. Thirteen [35%] patients were outdoor cases while 24 [65%] were in-patients. Average time of reconstruction was 40 minutes, which was done under general anesthesia in 21[57%] patients and under local anesthesia in 16 [43%] cases. Mean hospital stay of the indoor cases was 26 hours. There was no flap loss except for marginal necrosis in 04 [11%] patients. Wound infection and wound dehiscence was observed in 03 [08%] patients. Sensations were completely intact in 29 [78%] patients and aesthetically 28 [76%] patients gave normal look at the end of two years [2Y]. Twenty-seven [74%] patients had no change in speech and only one [3%] patient had unsatisfactory speech after 2 years. Varying degree of microstomia was observed in all the cases at immediate postoperative stage of one month but 35 [95%] patients showed gradual improvement with active mouth opening and stretching by prosthetic splints over 2 years. The Karapandzic technique of lip reconstruction is strongly recommended over the other techniques as it is a single stage, quick and safe procedure which gives cosmetically and functionally excellent results. Microstomia, occuring in early postoperative stage, shows gradual improvement on long-term follow-up

Superficial sural artery flap: a simple solution for difficult heel defects

The management of soft tissue defects over the Achilles tendon, malleoli and heel remains a challenge to plastic surgeons. Skin grafts are not suitable and donor sites for local flaps are limited. Free muscle transfer poses numerous technical difficulties. The objective of this study is to evaluate the efficacy of sural artery flap for hind foot defects in our population. Design: A prospective study was conducted on patients who presented with soft tissue defects of the heel and ankle area. Place and Duration of the study: The study was conducted at the Department of Plastic and Reconstructive Surgery, Combined Military Hospital, Rawalpindi, over a four-year period [August 1995 to January 2000]. Subject and Twelve patients with hind foot defects, which required flap coverage, were include. Preoperative data was recorded and photographs were taken. A distally-based superficial sural artery flap was used in all patients. Pre-operative flap dimensions were recorded and photographs taken. Follow-up was carried out keeping in view the flap survival, functional outcome and donor site morbidity. Out of twelve patients there were ten males and two females aged 12 to 60 years. Most of them had defect due to trauma except 02 that had soft tissue loss following tumor excision. The mean dimensions of the flaps used were 7 x 8.7cm. Postoperatively 10 flaps survived completely while marginal necrosis was seen in two patients and the donor site morbidity was not severe. All patients were ambulatory in normal footwear after this procedure. Conclusions: The distally-based superficial sural artery neurocutaneous flap is a single stage, quick, easy and safe reconstructive option in our patients with hind foot defects

Results of surgical procedures for brachial plexus injuries due to penetrating trauma

The incidence of brachial plexus injuries is on the rise primarily due to the increase in road traffic accidents and the upsurge of violence in our society in general. Inappropriate and poorly timed management can lead to disastrous consequences, not only for the individual but also for the society as a whole. Twenty four patients who received penetrating wounds resulting in damage to the brachial plexus are presented. The time lapse between injury and surgery, level and extent of disability, mode of evaluation and the surgical procedures performed are discussed. Exploration and repair was performed in patients who presented early and in those with total lesions without evidence of recovery. Muscle transfer was the mainstay in patients who presented late and in whom some muscle groups had been spared. The results of surgery have been encouraging although the period of follow-up is relatively short. It is concluded that with the judicious use of intact muscles, nerve repair and grafting in selected cases and extensive physiotherapy useful function can be achieved even in patients with extensive post ganglionic lesions

Management of congenital cleft lip: an eight-year experience

From1988 to1996, 461 patients with congenital cleft lip underwent a total of 505 surgical procedures. Most of the patients were operated upon in their childhood, but 16% underwent surgery in their teens and early adult life. A unilateral deformity was present in 384 patients, 73 had a bilateral cleft while 4 patients had a median cleft. The epidemiological data was consistent with that reported in literature. Millard repair was the commonest procedure for unilateral clefts being used in 86% cases. For the bilateral clefts an Hagedorn or a Millard procedure was used. The overall complication rate was 3%, with 3 perioperative deaths in the series. Results were assessed at a minimum of 6 months post-operatively. In 79% of patients, a good result was obtained. Secondary/revisional surgery was required in 33[7.2%] patients. About 25% of patients with bilateral clefts had a fractured premaxilla and it is recommended that surgery be performed early in these patients. Patients with incomplete clefts had a slightly higher percentage [83.1%] of good results as compared to complete clefts [77.2%]. This indicates that the more severe the deformity, the poorer the results. It was shown that results have more to do with the attention to detail and skill of the individual surgeon rather than any specific technique

Late presentation of carcinoma breast in Pakistan women

Carcinoma of the breast is one of the commonest malignancies in women worldwide. Patients in our country usually present late with advanced disease. This study was conducted to delineate the reasons for this late presentation and its impact on the management and prognosis. Delay in presentation was attributed by 73 152.5%] to painlessness of the lump. Sixty-seven patients[48.2%] were afraid of surgery in general while 46133%] were scared of losing the breast. Non availability of a female doctor was cited as a delaying factor by 64 [46%] patients. Lack of education per se was not a significant factor in late presentation as 129 of 139 patients [92.8%] were literate with only 10 [7.2%] being totally illiterate. Fifty one [36.8%] had completed intermediate or higher level of education. Increasing parity was another factor for delay with 12 of 15 [80%] of the nulliparae presenting within one month while only 5 [9.2%] of the 54 women with 4-8 children presenting in this time period. The delay in presentation was found to have a direct brearing on the stage of the disease. 58 patients [31.2%] reported within one month of the onset of symptoms and 22.8%] were in clinical stage-I. 91 patients [48.9%] presented between 1-6 months of the onset and only 7 [3.7%] were in stage-I of the 36 patients [19.3%] who presented after 6 month there were non in stage-I or stage-II