Outcomes of SUBGALEAL Drain Placement after two Burr-Holes Craniectomy for Chronic Subdural Hematoma.

OBJECTIVE: To evaluate the efficacy and complications of subgaleal drain placement after two burr-holes evacuation of chronic subdural hematoma (CSDH). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Neurosurgical unit of the Lady Reading Hospital, Peshawar, from April to November 2021. METHODOLOGY: Sixty-four consecutive patients diagnosed with surgically significant unilateral chronic subdural hematoma were prospectively included after obtaining informed consent. All the patients underwent two burr-holes craniectomies and evacuation, followed by subgaleal drain placement. Patient demographics, pre- and postoperative clinical information including hematoma resolution and complications were collected. RESULTS: This study included 44 (69%) males and 20 (31%) females with a mean age of 70.1 ± 8 years. The most common presenting symptoms were headaches (70%) and confusion (68%). Eighteen patients (28%) were taking warfarin or other anticoagulants, whereas, 23 patients (36%) were taking antiplatelet medications at the time of presentation. Thirty-six (56.3%) patients had a history of head trauma. Warfarin use was statistically significant in the patients with no history of head injury. Fifty-five patients (85%) showed no significant recurrence on the 2 week postoperative computed tomography (CT) scan. None of the patients had intraparenchymal hematoma or contusion of iatrogenic origin on postoperative CT scans. CONCLUSION: Subgaleal drain placement after two burr-holes craniectomy led to high-resolution rates. However, no parenchymal injuries were attributed to the procedure. KEY WORDS: Chronic subdural hematoma, Subdural drain, Subperiosteal drain, Burr-hole craniostomy.

Surgical Management Of Irreducible Atlanto-Axial Dislocation With OS Odontoideum And Klippel-Feil Syndrome.

Klippel-Feil syndrome (KFS) is the congenital fusion of two or more cervical vertebrae which is often associated with various other abnormalities in the cervical spine. Involvement the upper cervical segments leads to atlanto-axial instability which manifests as progressive neurological symptoms due to compression on the spinal cord. These cases pose a surgical challenge due the abnormal and unique anatomy of each patient. A 37-year-old patient presented with neck pain and cervical myelopathy due to a posterior subluxation of C2-3 fused segment over C4-6 fused segment. The patient had an os odontoideum, incomplete posterior arch of C1, anomalous course of vertebral artery and C3 hemi-vertebra. The patient was successfully managed with transoral odontoidectomy and occipeto-cervical fusion. Irreducible atlanto-axial dislocation in a patient with an abnormal upper cervical spine anatomy may require transoral decompression followed by posterior fusion.

Transoral Odontoidectomy - Our Experience in A Limited-Resource Setup.

BACKGROUND: Although posterior procedures are used for most cases of basilar invagination, transoral decompression is an important tool in complex deformities with severe degeneration and neural compression. METHODS: Consecutive patients who underwent transoral odontoidectomy for basilar invagination and atlantoaxial dislocation at the neurosurgical unit of Lady Reading Hospital Peshawar between June 2016 and January 2022 were retrospectively included. Preoperative and postoperative neurological, clinical, and radiological parameters were recorded and compared. RESULTS: Of the 33 patients included in this study, 22 were men and 11 were women. The mean age was 23.4 years ±8.4 years (mean ± standard deviation). The most common presenting symptoms were gait abnormalities and neck pain. A total of 28 patients were treated for the first time, while 5 patients had prior posterior fusion. The mean distance of the tip of the dens above the chamberlain line was 8.9 ± 4.2 mm, while the mean anterior atlantodental interval was 6.5 ± 2.1 mm. Seven patients had an anomalous course of vertebral artery on at least one side. A total of 28 patients improved significantly, while 5 patients did not improve at the follow-up. The mean follow-up was 8.5 months ±6.3 (mean ± standard deviation). The mean Nurick and Modified Japanese Orthopedic Association scores improved postoperatively (P < 0.05). Three patients underwent reoperation including one with vertebral artery injury. Three patients underwent tracheostomy. CONCLUSIONS: With proper patient selection, transoral odontoidectomy can be safely performed in a limited-resource setting.

Case of pedicle lag screw fixation for oblique axis body and pars fractures with displacement.

Background: Multiple axis fractures with instability are rare and appropriate treatment modalities have not been established. Case Description: A 33-year-old male presented with severe neck pain, bilateral upper-extremity numbness, and brisk reflexes in both lower extremities of 14 days' duration after a car accident. The cervical CT revealed an oblique C2 body fracture and asymmetrical neural ring fractures, while the MRI showed a normal C2-3 disk. As traction failed to reduce the fracture, the patient underwent an anterior retropharyngeal approach to release the fracture fragments, followed by posteriorly passing bilateral C2 pedicle lag screws. Eight months later, the patient exhibited full range of motion across the C1-2 level with fusion of the previously noted fractures. Conclusion: A 33-year-old male with an unstable C2 body fracture and asymmetrical neural ring fractures successfully underwent an anterior retropharyngeal approach to release the fracture fragments, followed by posteriorly passing bilateral C2 pedicle lag screws to achieve stability/fusion.

Anterior transcervical release with posterior atlantoaxial fixation for neglected malunited type II odontoid fractures.

Background: Type 2 odontoid fractures are associated with a high rate of nonunion without surgical treatment. If neglected, they may become fixed in an abnormal position, causing progressive myelopathy. Conventionally, odontoidectomy or transoral release is performed to relieve symptoms in such cases. Here, were report our experience with a transcervical approach for odontoid release (i.e., of a chronically fractured dens) followed by a posterior C1-C2 fusion. Methods: The 11 patients (2017-2021) retrospectively included; in this study, all had a history of remote trauma and the radiological appearance of an old odontoid fracture that was displaced and could not be reduced with traction. There were eight males and three females who averaged 52.6 years of age. Results: All 11 patients underwent anterior retropharyngeal release with a C4-C5 level incision followed by a posterior C1-C2 fusion. The mean Japanese orthopedic association on presentation was 9.9 ± 2.7 which improved to 13.8 ± 2.7 on final follow-up (P < 0.01). Patients were followed an average of 9.6 months ± 4.4 (mean ± SD) postoperatively during which time they all clinically improved. Conclusion: Anterior release through a retropharyngeal approach coupled with posterior C1-C2 instrumentation proved to be an effective alternative to the traditional transoral approach to treat a chronic malunited odontoid fracture.

Cost difference of enhanced recovery after surgery pathway vs. Conventional care In Elective Laparoscopic Cholecystectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a perioperative bundle aimed to reduce surgical stress. Significant reductions in length of hospital stay and associated costs have been reported in multiple studies in all surgical specialties. Purpose of the study was to compare the effect of Enhanced recovery protocols vs. conventional care on perioperative length of hospital stay and cost per patient in a government funded hospital. METHODS: this randomized controlled trial was conducted in the department of General Surgery, unit B, Lady reading hospital, Peshawar from April to December 2018. One hundred and fifty patients were selected based on consecutive sampling. Random allocation into two groups of 75 (ERAS vs Conventional) was done based on computer generated numbers. Length of hospital stay and total direct costs were calculated. Frequency of Surgical site infections, readmissions and mortality was also recorded. Patient reported outcomes were recorded by Surgical Recovery Scale SRS. RESULTS: Patients in the Enhanced recovery group showed a significant reduction in length of hospital stay 28.9 hours in ERAS group vs 40.5 hours in Conventional care group (p<0.001). Total per patient cost was reduced in the ERAS group PKR 6804 in comparison to the conventional care PKR 7682 (p<0.001). Patient reported outcomes measured on Surgical Recovery Scale SRS on discharge, day 3 of discharge and day 10 of discharge showed no significant difference between the two groups. CONCLUSIONS: Enhanced recovery protocols demonstrated a reduction in length of perioperative hospital stay and total cost despite similar post discharge recovery scores on Surgical Recovery Scale SRS and no increase in readmissions.