Burr Hole Evacuation of Extradural Hematoma in Mass Trauma. A Life Saving and Time Saving Procedure: Our Experience in the Earthquake of 2005.

AIM: To observe the outcome of burr hole evacuation of extradural hematoma (EDH) in mass head injury. MATERIAL AND METHODS: This study included patients of any age who sustained head injury in the earthquake of October 8, 2005, were diagnosed as EDH on computed tomography (CT) scan and were admitted in the neurosurgery ward over a period of 3 days. All patients were followed by serial CT scans and neurological assessments. RESULTS: A total of 36 patients were included in this study. There were 25 male and 11 female patients and the age range was from 5 years to 50 years. All cases were the victim of the earthquake. All patients underwent surgery for evacuation of EDH through a single burr hole. One patient required craniotomy for EDH due to neurological deterioration on the second postoperative day, and 1 patient died. CONCLUSION: As EDH is potentially fatal lesion, evacuation of EDH through a single burr hole has good outcome with less chances of recurrence and complications in mass head injured patients as seen with earthquakes.

FREQUENCY OF EXTRADURAL HAEMATOMA IN PATIENTS WITH LINEAR SKULL FRACTURE.

BACKGROUND: Apparently normal looking patients after traumatic brain injury can have serious neurological deterioration, and one of the common causes of such deterioration is extradural haematomas. This study was conducted to determine the frequency of extradural hematoma and common types of trauma leading to it among patients presenting with skull fracture due to head injury. METHODS: This cross-sectional study was conducted in the department of Neurosurgery Ayub Medical College, Abbottabad from June 2011 to June 2012. All patients who were suspected to have Skull fracture on X-ray skull, during the study period, were included in study after informed consent and later on CT-Scan brain was done to see for extradural hematoma. Findings were recorded on a predesigned pro fonna including demographic data, radiological findings and the type of head trauma. RESULTS: Out of 114 patients 85 (74.5%) were males and 29 (225.4%) were females. Age ranged from 2 to 70 years (18.23 +/- 16.5 years). Among these patients the most important cause of head injury was fall from height in 65 (57%), followed by road traffic accidents in 39 (34.2%), and assault in 10 (8.8%) patients. The most common site of fracture was parietal in 49 (43%) of patients, followed by frontal bone in 28 (24.6%) of patients, occipital bone in 24 (21.1%) of patients, and temporal bone in 23 (20.2%) of patients. Frequency of extradural hematoma among linear skull fracture was in 34 (29.8%) patients. Extradural hematoma was most common with parietotemporal linear skull fractures (73.5%). CONCLUSION: Extradural haematoma occurs commonly with linear skull fractures, so patients with linear skull fracture should be properly evaluated with CT brain.

RADIOLOGICAL OUTCOME OF TRANSPEDICULAR SCREWS FIXATION IN THE MANAGEMENT OF THORACOLUMBAR SPINE INJURY.

BACKGROUND: Traumatic fracture of the spine 'is a serious neurosurgical condition that has serious impact on the patient's quality of life. Thoracolumbar junction is the most common site of spinal injuries. The aims of management of thoracolumbar spinal fractures are to restore vertebral column stability, and to obtain spinal canal decompression. This ultimately leads to early mobilization of the patients. This study was conducted to compare preoperative and post-operative vertebral height, kyphotic angle and sagittal index in patients treated with pedicle screws and rods in thoracolumbar spine fractures. METHODS: This cross-sectional study was conducted in the department of Neurosurgery, Hayatabad Medical Complex, Peshawar from 1st. February 2010 to 31st. July 2011. A total 161 patients with unstable thoracolumber spine fracture were included in this study. In these patients fixation was done through transpedicle screws with rods. Anteroposterior and lateral views X-rays of thoracolumbar spine were done pre and post operatively. RESULTS: Out of 161 patients, 109 (67.7%) were males and 52 (32.3%) females. The age of patients ranged from 20 to 70 years (mean 42.2 years) with 71 (44.1%) in the age range of 31-40 years. Preoperative average vertebral height was 9.4194. mm while postoperative average was 19.642 mm. The mean kyphosis was 23.06 degrees preoperatively. Immediately after surgery the average correction of kyphosis was 9.45 degrees. The pre-operative average sagittal index was 19.38 degrees, which was reduced to an average 5.41 degrees post operatively. CONCLUSIONS: Transpedicular fixation for unstable thoraco-lumbar spinal fractures achieves a stable fracture segment with improvement of vertebral height, kyphotic angle and sagittal index. Hence, preventing the secondary spinal deformities.

EARLY RESPONSE OF LOCAL STEROID INJECTION VERSUS MINI INCISION TECHNIQUE IN TREATMENT OF CARPAL TUNNEL SYNDROME.

BACKGROUND: Carpal tunnel syndrome (CTS) is one of the commonest peripheral neuropathies which effects mainly middle aged women. Different techniques are being tried to decrease the postoperative pain in patients operated for CTS. The objective of this study was to compare effectiveness of local injection of steroid and mini incision technique in the treatment of carpal tunnel syndrome. METHODS: This randomized control trial was conducted at department of Orthopedics and department of Neurosurgery, Ayub Teaching Hospital, Abbottabad from Aug 2011 to Feb 2013. A total of 116 patients of CTS were randomly allocated to either of the two groups.58 Patient in Group A were subjected to local steroid injection and the same number of patient in Group B underwent mini incision technique. All patients of were advised to report to the OPD after one month to determine intervention effectiveness in terms of improvement in at least one grade of pain. RESULTS: In this study mean age of the patients was 32.8 +/- 5.1 years. Female gender was in dominance with 99 (86.3%) cases. In this study we compared the effectiveness of local steroid injection and mini incision technique in the treatment of carpel tunnel syndrome. We found out that the steroid injection was effective in 69.0% cases while mini incision technique was effective in 56.9% cases. The difference being statistically insignificant with a p-value of 0.17. CONCLUSION: The difference in pain after 1 month of the intervention was not statistically significant.

Comparison of the efficacy of single volar subcutaneous digital block and the dorsal two injections block.

BACKGROUND: Digital nerve blocks are commonly used as effective techniques of anaesthesia to allow a variety of surgical procedures performed on digits. This study was conducted to compare the efficacy of volar subcutaneous single injection block and the traditional dorsal two injections digital block. METHODS: This randomized controlled trial was conducted at Plastic and Reconstructive Surgery Department, Hayatabad Medical Complex Peshawar from December. 2009-10. A total of 126 patients with pathology distal to the first palmer digital crease divided into two equal groups. Group A received volar subcutaneous digital block while group B dorsal two injections block. Efficacy of digital block was measured in terms of time of onset of anaesthesia, which was the total time duration after administering local anaesthetic to loss of pinprick sensation and total duration of anaesthesia, which was defined as the time period from onset of block (loss of pinprick sensation) till the appearance of pain which required additional local anaesthetic or postoperative analgesia. RESULTS: A total of 126 patients were studied, 63 in each group. Of the total patients, 102 (81%) were male and 24 (19%) female with a mean age of 27 ± 4.2 years (range 17-60 years). The mean time of onset of anaesthesia from injection till the loss of pin prick sensation was 3.32 ± 0.42 minutes for volar single injection group and 4.53 minutes ± 0.57 minutes for dorsal two injections group (p = 0.049). Similarly the mean total duration of anaesthesia for the volar subcutaneous group was 271.9 ± 29.34 minutes while for the dorsal two injections group, it was 229.52 ± 28.82 minutes (p = 0.415). CONCLUSION: Single injection volar subcutaneous digital block provides faster onset of anaesthesia, produces predictable, consistent dense anaesthesia of all of the fingers with the help of single injection prick.

Lumbar disc herniation in patients with chronic backache.

BACKGROUND: Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, social, and health impact. This study was conducted to determine the frequency of lumbar disc herniation and its different levels, among patients with chronic backache. METHODS: This cross sectional study was conducted in the department of Neurosurgery, Ayub Medical College Abbottabad from January 2011 to January 2013. All the patients presenting with chronic low backache of either gender above the age 14 years were included in the study. Magnetic resonance imaging (MRI) was done in all the patients included in the study to look for lumbar disc herniation. RESULTS: A total of 477 patients with chronic low backache were included in the study out of which 274 (57.4%) were males. Age of the patients ranged from 19 to 75 (39.92 +/- 12.31) years. Out of 477 patients 38 (7.9%) had significant radiological evidence of disc prolapse at lumbar vertebral levels, with 26 (9.5%) males and 12 (5.9%) females. Among these 38 patients with inter-vertebral disc, 20 (52.6%) of patients had disc herniation at L5-S1, 15 (39.5%) at L4-L5, 2 (5.26%) cases at L3-L4 level and only one case (2.6%) had the involvement of L2-L3 level. No cases of L1-L2 disc prolapse were found. CONCLUSION: Patients with chronic backache can have inter-vertebral lumbar disc prolapsed disease. Middle age group are more affected by lumbar disc disease especially at the lower lumbar regions.

Spectrum of trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) is a very painful condition characterized by paroxysmal shock like pain in the distribution of one or more branches of trigeminal nerve caused by neurovascular conflict at the root entry zone of trigeminal nerve. This study was conducted to analyse the demography and pattern of TN in our setup. METHODS: This descriptive study was conducted in the Oral Surgery unit, Department of Dentistry, Ayub Medical College. Abbottabad, from April 2009 to October 2011. A total of 117 patients were included in study by convenience (non probability) sampling technique. All the patients presenting with the clinical features of TN were included in study. RESULTS: Out of 117 cases, 49 (41.9%) were males and remaining 68 (58.1%) were females. Age of the patients ranged from 32-72 (53.90 +/- 10.21) years. Right side was involved in 63 patients (53.8%), while the left side was involved in 51 patients (43.60). In only three cases (2%) there was bilateral involvement. The maxillary division was involved in 68 cases (58.1%) and mandibular division was involved in 37 cases (31.6%). The most common site of involvement was infra-orbital, which was involved in 68 cases (58.11%). The next common site was the mental nerve which showed involvement in 35 cases (29.9%) followed by inferior alveolar nerve which was affected in 14 cases (12%). Thirty three (28.2%) patients were having mild pain. 54 (46.2%) patients having moderate, 21 (18%) patients with severe and 9 (7.7%) patients were having very severe pain. No patient in our study had a family history of TN. Among our patients 103 (88%) patients underwent dental extraction for the same pain. CONCLUSION: The incidence of TN is more in old age especially in females. TN is frequently misdiagnosed in with tooth ache, so there is need to educate the medical practitioners and masses in order to avoid un-necessary tooth extractions.

Outcome of transcranial repair of traumatic CSF rhinorrhea.

BACKGROUND: Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Posttraumatic CSF rhinorrhea is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcomes of patients with transcranial subfrontal approach for posttraumatic CSF rhinorrhea approach may help the neurosurgeon in the decision-making process. This study was conducted to analyse the outcome of trans-cranial sub-frontal approach for traumatic CSF rhinorrhea, with duroplasty and fibrin glue. METHODS: This study was carried out in the Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2007 to Jun 2011. All patients undergoing trans-cranial sub-frontal repair of traumatic CSF fistulas were included. Where possible primary dural repair was performed under hypotensive general anaesthesia and in the cases where it was not possible, graft was used. This was followed by application of fibrin glue at the repaired site. Graft materials used in this study were taken from fascia lata, pericranium, and temporalis fascia. RESULTS: Out of 27 patients 21 were men and 6 were women. Age of the patients ranged from 17 to 56 (34.5 +/- 4.6) years. Main causes of trauma were road traffic accidents (23, 85%), fall from height (3, 11%), and assaults (1, 4%). In 23 (85%) cases no CSF leak was observed in immediate postoperative period as well as during the follow-up visits while in 3 (11%) cases additional lumber punctures were required to augment the repair. One patient failed to respond to surgery and lumbar drainage. CONCLUSION: The CSF rhinorrhea is commonly seen in patients with anterior skull fractures secondary to head injury. Initially conservative trail should be given to the patients, if it fails then on-lay dural technique followed by fibrin glue application through transcranial approach has good outcome with less chances of complications.

Efficacy of endoscopic third ventriculostomy in non-communicating hydrocephalus.

BACKGROUND: Hydrocephalus is common problem requiring either extra-cranial (shunts) or intracranial (ventriculostomy) diversion of cerebrospinal fluid. Endoscopic third ventriculostomy obviates all the complications of shunts and has been accepted as the procedure of choice for the treatment of obstructed hydrocephalus in adults and children because of the minimally invasive nature. This study was conducted to determine the efficacy of endoscopic third ventriculostomy in the treatment of non-communicating hydrocephalus. METHODS: This cross sectional descriptive study was done in neurosurgery department of Hayatabad Medical Complex, Peshawar, from 2nd February 2011 to 1st march 2012. A total of 171 patients with non-communicating hydrocephalous, irrespective of gender discrimination and Glasgow coma scale score of 10 and above were included in this study. Patients below one year of age, with lesion in the floor of the third ventricle or near basilar artery, and hydrocephalus with infected CSF or haemorrhage were excluded. Hydrocephalous was diagnosed on CT-scan brain. All the patients were followed up till 72 hours post-operatively for the determination of effectiveness in terms of improvement in Glasgow coma scale by at least 2 points. All the above mentioned information including name, age, gender and address were recorded in a predesigned proforma. The data was analysed using SPSS-17. Frequency and percentage was calculated for categorical variables. Mean +/- SD was calculated for age. RESULTS: A total of 171 patients with non-communicating hydrocephalous were included in the study. Out of 171 patients, there were 104 (60.8%) males and 67 (39.2%) females. Age ranged from 1-70 years with majority of the patients was below 10 years of age. Majority of the patients had hydrocephalus due to tuberculous meningitis 39.2% of the whole. In 134 (78.4%) patients the procedure was effective. Procedure was more effective in hydrocephalus due to space occupying lesion. CONCLUSION: Endoscopic third ventriculostomy is a very effective procedure for the treatment of non-communicating hydrocephalus.

Cervical spinal injuries in moderate to severe head injuries.

BACKGROUND: Traumatic Brain Injury (TBI) is the leading cause of death in all age group. The incidence of CSI increases with the severity of TBI so prompt care of cervical spine is necessary in all patients with moderate to severe head injury. The objective of this study was to determine the frequency of cervical injury in patients with moderate to severe head injury and different types of trauma. METHODS: This descriptive cross sectional study was conducted in department of Neurosurgery Ayub Medical College, Abbottabad from October 2011 to October 2012. A total of 369 patients were included in this study by consecutive (non probability) sampling. All patients were subjected to X-rays and CT-Scan of the skull for evaluation of head injury. X-rays and CT scan with MRI of cervical spine were done for evaluation of cervical spinal injury. RESULTS: A total of 369 patients were included in our study, out of which 276 (74.8%) were males and 93 (25.2%) were females. Age of the patients ranged from 3-90) years with mean of 31.93 +/- 21.35. Among these patients most common cause of injury was fall 196 (53.1%), whereas the RTA was 159 (43.1%) and assault was 14 (3.8%). Out of the 369 patients 42 (11.3%) were found to have cervical spinal injuries. CONCLUSION: The frequency of cervical injury associated with moderate to severe head injury remains the same in all over the world with minor difference in percentages; that we have observed in our study. Furthermore, we have observed that cervical injury is directly proportional to the severity of head injury. All the head injured patients should be suspected of having cervical spinal injury unless proved otherwise.

Demographics of basal cell carcinoma and its surgical management.

BACKGROUND: Basal cell carcinoma (BCC) is the most common, slow growing epidermal skin tumour and an increase in its incidence has been noticed in the past decades. Different treatment options include surgical and non-surgical measures. Surgical options include surgical excision, cryosurgery, curettage, electrodessication and Mohs micrographic surgery. Non-surgical treatments options are 5-flourouracil, photodynamic therapy, immunomodulation and radiotherapy. This study was conducted to determine the demographics of facial BCC and its rate of incomplete excision and recurrence. METHODS: Clinically diagnosed facial BCCs were included in this prospective descriptive study. Tumours were excised with 3-5 mm clinically palpable safe margins and were sent for histopathological confirmation and margin clearance. All patients were followed for a minimum of two years to look for any recurrence. The demographic data, site, clinical presentation, size of the lesion, excision margins, reconstructive options, complications, histopathological margin clearance and recurrence was recorded and analysed. RESULTS: A total of 139 cases were recruited in this study. Four cases were lost in follow-up. Out of remaining 135 patients including 78 males and 57 females with a mean age of 58.6 years were studied. The commonest site of involvement was nose (45.9%), followed by periocular (28.1%) and cheek (15.6%) regions. The most common clinical type was nodular (51%) followed by ulcerative (38.5%). In majority of the cases, the resulting defect after excision was reconstructed with local flaps (57.8%). Majority (77.8%) of tumours had histopathologically clear margins while 20% had tumour involvement. During 2 years follow-up period, 8.9% patients had tumour recurrence.

Frequency of conservatively managed traumatic acute subdural haematoma changing into chronic subdural haematoma.

BACKGROUND: Traumatic brain injury represents a significant cause of mortality and permanent disability in the adult population. Acute subdural haematoma is one of the conditions most strongly associated with severe brain injury. Knowledge on the natural history of the illness and the outcome of patients conservatively managed may help the neurosurgeon in the decision-making process. METHODS: We prospectively analysed 27 patients with age ranges 15-90 years, in whom a CT scan diagnosis of acute subdural haematoma was made, and in whom craniotomy for evacuation was not initially performed, to the neurosurgery department of Ayub Teaching Hospital Abbottabad (2008-2011). Patients with deranged bleeding profile, anticoagulant therapy, chronic liver disease, any other associated intracranial abnormalities, such as cerebral contusions, as shown on CT, were excluded from this study. All patients were followed by serial CT scans, and a neurological assessment was done. RESULTS: There were 18 male and 9 female patients, Cerebral atrophy was present in over half of the sample. In 22 of our patients, the acute subdural haematoma resolved spontaneously, without evidence of damage to the underlying brain, as shown by CT or neurological findings. Four patients subsequently required burr hole drainage for chronic subdural haematoma. In each of these patients, haematoma thickness was greater than 10 mm. The mean delay between injury and operation in this group was 15-21 days. Among these patients 1 patient required craniotomy for haematoma removal due to neurological deterioration. CONCLUSION: Certain conscious patients with small acute subdural haematomas, without mass effect on CT, may be safely managed conservatively, but due to high risk of these acute subdural haematoma changing into chronic subdural haematoma these patients should be reinvestigated in case of neurological deterioration.

Pre-hospital management of spinal injuries in a natural disaster.

BACKGROUND: Spinal injuries are one of the most devastating and crippling conditions known to mankind. Natural calamities follow no rules, and all have the potential of devastating medical and public health resources, earthquakes being the deadliest. The incidence of spinal injuries increases by leaps and bounds in such calamities. Improper pre-hospital management and inadvertent manipulation of the spine during rescue and transfer can aggravate the damage. This study was conducted in order to access the level of pre-hospital care that had been provided to the patients with spinal injuries reaching Ayub Teaching Hospital, Abbottabad after the October 2005 earthquake. METHODS: This study was conducted in the department of Neurosurgery, Ayub Medical College after the earthquake of October 2005. All patients sustaining spinal injuries were included in the study. Demographic data like age, gender and time of arrival at hospital were recorded. The important aspects of pre-hospital care like spinal immobilisation, intravenous access, fluid resuscitation, catheterisation, pain killers and intravenous steroids administration were also recorded. RESULTS: Out of the 83 patients with spinal injuries, 55 (66.26%) were females and 28 (33.7%) were males. Age ranged from 12-68 years (mean 26.6 +/- 13.2 years). At the time of presentation 70 (84.3%) patients had complete spinal injury whereas 13 (15.6%) had incomplete spinal injury. Sixty-one (73.5%) patients were paraplegic and 22 (26.5%) cases were quadriplegic. Only 8 (9.6%) patients were brought to the hospital after proper spinal immobilisation on the spinal boards. Intravenous line was maintained in 24 (28.9%) patients and only 18 (21.7%) received some sort of fluid resuscitation. Thirty-eight (45.7%) were catheterised. 18 (21.6%) received some sort of parenteral analgesics and 4 (4.8%) received steroids at the time of patients. Only 10(12%) were brought in properly equipped ambulances. CONCLUSION: Poor pre-hospital management of spinal injured patients depicts the lack of emergency preparedness as well as the lack of basic knowledge rescue teams and health care providers about the common trauma management measures. There is a dire need of educating rescue workers and volunteers about spinal injury in order to save lives minimise the secondary damage to already affected spine.

Predisposing factors, clinical presentation and outcome of repeated aspiration in cerebral abscess through a drainage tube in situ.

BACKGROUND: Cerebral abscess is a serious and life threatening complication of several diseases. Aspiration of the abscess cavity versus excision of capsule are still in debate for the capsulated, large, superficially located abscesses especially in patients with poor surgical fitness. The objective of this study was to look for the clinical presentation and outcome of patients with repeated aspiration in cerebral abscess through a drainage tube in situ. METHODS: This prospective study was conducted in Department of Neurosurgery, Ayub Medical College, Abbottabad from Jan 2010 to Jun 2011. Twenty-three patients with age ranges 6-21 years who had large, solitary, capsulated, superficially located abscesses, were included in this study. These patients had poor American Society of Anaesthesiologists (ASA) grading (grade III and IV). After thorough clinical examination and workup, patients were subjected to operative procedure. The procedure included placement of 8 size nasogastric tube in the abscess cavity through a single burr hole. Under strict aseptic conditions, repeated aspiration of pus was done through the drain daily for 2-4 days consecutively at intervals of 24 hours. The demographic data. predisposing factors, clinical presentation, and outcome of patients with repeated aspiration through drain placed in abscess cavity were recorded. Postoperatively, gadolinium enhanced CT-scan was done twice in the first month at the span of two weeks each, later on monthly for next 3 months. The CT-scans were reviewed for recurrence or any other possible intracranial complications. Patients were followed for duration of 3 to 6 months. RESULTS: The predisposing factors found were congenital heart disease in 7 (30.4%) patients, spread of contagious infections like mastoiditis/Chronic suppurative ottitis media in 5 (21.7%) patients, sinusitis in 2 (8.6%) patients, meningitis in 5 (21.7%) patients, septicemia in 3 (13.7%) patients, and penetrating cranial injury in 1 (4.34%) patients. In 16 (69.5%) patients presenting complaints were headache and vomiting, altered sensorium in 8 (34.7%) patients, hemiparesis in 9 (39.1) patients, aphasia in 3 (13.1%) patients, papillodema in 2 (8.7%) patients, and seizures in 1 (4.34%) patients. The abscess resolved in 19 (82%) of patients, recurrence occurred in 2 (8.7%) of patients, and death occurred in 2 (8.7%). CONCLUSION: Cerebral abscess is a life threatening condition requiring aggressive management measures. Aspiration of cerebral abscess with repeated aspiration through a drainage tube is a life saving in patients with poor ASA grade with low recurrence of abscess formation and low mortality.

Transnasal endosocpic repair of cerebrospinal fluid rhinorrhoea.

BACKGROUND: Cerebrospinal fluid (CSF) leaks can arise as a complication of trauma, hydrocephalus, endoscopic sinus surgery or it may occur spontaneously without any identifiable cause. Surgical repair is recommended in patients who do not respond to the conservative management. In recent years transnasal endoscopic approach has become the preferred method for repairing the CSF leaks and better outcomes have been reported as compared to the intracranial approaches that were previously used. Objective of this study was to analyse the outcome of transnasal endoscopic repair of CSF rhinorrhoea. METHODS: This prospective study was conducted in the Department of Neurosurgery, Ayub Medical College, Abbottabad, from March 2007 to March 2010. Twenty-one patients with CSF rhinorrhoea were included in study that were diagnosed on the basis of clinical evaluation, glucose concentration of nasal discharge, computed tomography (CT) and magnetic resonance imaging (MRI). These patients did not respond to conservative management and were operated transnasally using rigid endoscope. Patients were followed up for a mean duration of 9 months and the outcome was analysed. RESULTS: The patients included in the study ranged in the age group of 12-55 years. Among the patients 13 (57%) were female and 8 (38%) were males. The cause of CSF rhinorrhoea was traumatic in 16 (76.19%), Idiopathic or spontaneous in 4 (19.04%) and 1 (4.7%) case was related to endoscopic surgery for pituitary macroedenoma. In 10 (47.6.8%) patients the site of leak was cribriform plate, 5 (23.8%) had from sphenoid, 4 (19.04%) from frontal sinus and in 2 (9.5%) Ethmoid was affected. Primary surgery was successful in 17 (80.95%) of cases. In 2 (9.5%) cases re-exploration had to be performed. In 1 patient re-exploration had to be done for the third time. Overall success rate was 95%. One patient presented with CSF leak and meningitis 1 month after surgery and unfortunately died. CONCLUSION: Transnasal endoscopic repair of CSF rhinorrhoea is highly successful, safe and less traumatic.

Clinical and radiological findings in Arnold Chiari malformation.

BACKGROUND: The Chiari Malformation I (CMI) is a disorder of uncertain origin that has been traditionally defined as downward herniation of the cerebellar tonsils through the foramen magnum. The anomaly is a leading cause of syringomyelia and occurs inassociation with osseus abnormalities at the craniovertebral junction. In contrast to other Chiari malformations, CMI tends to present in the second or third decade of life and is sometimes referred to as the 'adult-type' Chiari malformation. The objective was to document clinical and radiological findings in Arnold Chiari Malformation-I. METHOD: This was a descriptive study carried out in Ayub Teaching Hospital Abbottabad at Neurosurgery Department during July 2008-July 2010. We examined a prospective cohort of 60 symptomatic patients. All patients underwent magnetic resonance imaging of the head and spine. RESULTS: There were 40 female and 20 male patients. The age of onset was 24.9 +/- 15.8 years. Common associated radiological problems included syringomyelia (60%), scoliosis (25%), and basilarinvagination (12%), increased cervical lordosis 5 (8.5%), and Klippel Feil syndrome 2 (3.3%). The most consistent magnetic resonance imaging findings were obliteration of the retrocerebellar cerebrospinal fluid spaces (70% patients), tonsillar herniation of at least 5 mm (100% patients), and varying degrees of post fossa anomalies. Linical manifestations were headaches, pseudotumor-like episodes, a Meniere's disease-like syndrome, lower cranial nerve signs, and spinal cord disturbances in the absence of syringomyelia. CONCLUSION: These data support accumulating evidence that CMI is a disorder of the para-axial mesoderm that is characterised by underdevelopment of the posterior cranial fossa and overcrowding of the normally developed hindbrain. Tonsillar herniation of less than 5 mm does not exclude the diagnosis. Clinical manifestations of CMI seem to be related to cerebrospinal fluid disturbances (which are responsible for headaches, pseudotumor-like episodes, endolymphatic hydrops, syringomyelia, and hydrocephalus) and direct compression of nervous tissue.

Management of thoracic trauma: experience at Ayub Teaching Hospital, Abbottabad.

BACKGROUND: The incidence of thoracic trauma has rapidly increased in this century of high speed vehicles, violence and various other disasters. It has been observed that chest intubation was required in more than 75% of patients. METHODS: This prospective study was performed in cardiothoracic surgery unit of Ayub Teaching Hospital Abbottabad from Jun 2007 to Dec 2007. A total of 114 consecutive patients with chest trauma were included in the study, their patterns of injuries classified, treatment strategies and outcome were recorded on a proforma. RESULTS: Out of 114 patients with chest trauma, 76 (66.65%) were having penetrating and 38 (33.33%) had blunt trauma. Haemothorax was detected in 67 (58.77%), Pneumothorax in 23 (20.17%), rib fracture in 11 (15.02%) and diaphragmatic injuries in 4 (3.5%) cases. Overall complication rate was 14%. Wound infection was present in 8 (7.01%) and empyema in 4 (3.5%). Mortality was 2.6%. CONCLUSION: Penetrating chest injuries were more common than blunt injuries and chest intubation with resuscitation was adequate in most of the patients.