Unusual Local Therapies Used for the Treatment of Low Back Pain and Sciatica: Concepts and Approaches.

Background and objective Low back pain (LBP) and sciatica are major healthcare issues globally. Since patients may seek various ways to cure their ailments, these conditions are managed not just by physicians, but many other health-related professionals provide alternative treatment options for it as well. We conducted this study to examine a local subset of patients who used stabbing their back and legs as a treatment option for curing LBP and sciatica. Materials and methods This cross-sectional study was conducted in the outpatient clinic of the Neurosurgery unit of Government Naseer Ullah Babar Memorial Hospital, Peshawar, Pakistan, from July 2019 to March 2020. Patients who presented to the outpatient department (OPD) with complaints of LBP with or without sciatica, with a history of invasive therapy in the form of stabbing the back or leg, or drawing blood from the veins of the lower limbs, were included. All other patients with LBP seeking neurosurgical advice were excluded from the study. The study was approved by the management of the hospital and informed consent was obtained from the patients before interviewing them. Special permission was taken for publishing the photographs. The demographics and clinical information related to patients, such as age, gender, duration of symptoms, time since the local therapy, particulars of the treatment provider, any relief experienced by the patient, duration of relief, the patient beliefs/notions about the therapy and disease, and education level of the patients, were recorded on a predesigned form after taking informed consent. The study was done on purposive sampling. The data was presented in tables and charts and was analyzed using SPSS Statistics version 20 (IBM, Armonk, NY). Results During the study period, more than 8,000 patients visited the neurosurgical OPD, and the majority of them (>70%) sought treatment for LBP and sciatica. Of them, around 130 patients had a history of undergoing some alternative therapy that is not scientifically proven, and it was either in the form of stabbing the back or drawing blood from the veins in the lower limbs. Amongst these patients, almost 80% were males and 20% were females who had undergone this kind of treatment. The age range among the cohort was 25-68 years and the mean age was around 43 years. The duration of symptoms ranged from two months to nine years, and the time since the therapy and patient seeking medical advice ranged from three months to 4.5 years. The treatment had been provided by a local individual who did not hold any medical degree according to the patients in 100% (n=130) of the cases; 67% of patients felt they had experienced some relief from the therapy for a short period, which ranged from three days to one month. About the condition, none of the patients seeking the therapy knew it was nerve-related and were often confused about the term rugg (vessel in the native language) but could not differentiate it from the nerve. Of these patients, 76 required surgery while 54 were managed conservatively for LBP and sciatica. Conclusion A subset of the local population in our part of the world used stabbing the back and leg as a form of therapy for treating the problems of the lower back and sciatica. This has not been previously reported and has no scientific basis. Also, the majority of the patients were uneducated and had very little knowledge of the disease, and the treatment provider was a non-health-related professional.

Duration of In-hospital Stay for Elective Neurosurgical Procedures in a Tertiary Care Hospital.

OBJECTIVE: Public hospitals have fixed days with allotted time slots during which to perform neurosurgical elective cases. If emergency operations or other events preempt these scheduled time slots, the patient remains hospitalized, waiting in queue for a new time slot. We conducted this study to determine the number of days patients remained admitted waiting for elective cases in a tertiary care public hospital, which operates on fixed days. MATERIALS AND METHODS: This cross-sectional study was conducted in the Department of Neurosurgery Unit B, Medical Teaching Institution (MTI) - Lady Reading Hospital (LRH), Peshawar. We reviewed the admission charts and discharge slips of all patients who were admitted and underwent operations between September 2018 and August 2019. A form was made and was completed with each patients' records like age, gender, number of days spent preoperatively and postoperatively and the total duration of stay, indication for surgery (spinal, cranial, peripheral nerve), etc. Patients who had undergone elective neurosurgical procedures were included while those who had undergone emergency surgeries or had expired during the hospital stay, had been discharged or referred to other centers were excluded from the study. All the data were entered into the statistical software SPSS version 22 (IBM Corp., Armonk, NY) and were converted into tables and charts. RESULTS: A total of 1818 patients were admitted/discharged during the study period, and of them, 823 patients were admitted for elective neurosurgical procedures. There were 601 (73.7%) males and 222 (26.3%) females with a male to female ratio of approximately 3:1. The age range was from 09 days to 72 years and was further subdivided into six groups. The procedures were broadly divided into cranial, spinal, related to hydrocephalus (HCP)-related, and miscellaneous. Cranial procedures comprised of surgeries for brain tumors, transsphenoidal operations, vascular procedures for aneurysms, and nerve decompressions, and they comprised about 29.43% (n=244) while spinal procedures accounted for 317 (36.63%) procedures, the rest were related to HCP and miscellaneous. Preoperative and postoperative stay durations were calculated and then added to determine the total stay durations and were further stratified for the specific procedures and categorized into days and weeks. About 58.26% (n=143) of cranial cases, and 156 (49.36%) of spinal cases, 37.57% (n=65) of HCP-related cases, and 36.66% (n=41) of cases in the miscellaneous group had a duration of stay between eight days to more than three weeks.

Early Complications of Ventriculoperitoneal Shunt in Pediatric Patients With Hydrocephalus.

Objective Ventriculoperitoneal shunt (VPS) is the most commonly used procedure for the treatment of hydrocephalus (HDC), especially in children. However, this is prone to many complications, and requires repeated surgeries, which as such increases the morbidity of the patients. It is estimated that majority of the complications occurs in the immediate post-operative period and the rate of complications decreases over the time, with no impunity to these, though. We conducted this study to know about the complications of VPS in the early post-operative period, in pediatric patients with hydrocephalus. Materials and methods This descriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital, Peshawar, between June 2019 and January 2020 (seven months). All patients with hydrocephalus below 12 years of age, operated for the first time were included after taking an informed consent, while those with repeated shunt procedures and elderly patients requiring shunt were excluded from the study. Patients' details like age, gender, location, contact number, cause of hydrocephalus, date of shunt placement, type of surgery (elective or emergency) and any follow-up complications like failure, erosion, infections, ileus were noted on a predesigned proforma. After the surgery, patients were followed for a period of one month, and contacted either through the telephone or asked to visit in the outpatients on the specified days, and were evaluated for any shunt-related complications, and any of these complications suspected were further evaluated and noted. The data was analyzed using the statistical program SPSS version 19 (IBM Corp., Armonk, NY). Results are presented in the form of charts, tables and graph. Results During the study period, we evaluated a total of 151 patients; there were 78 (51.65%) males and 73 (48.34%) females with a male to female ratio approaching 1.1:1. The age range was from 22 days to 12 years. The mean age was 38.46 ± 7.53 months. The primary indications for the insertion of VP shunt were: congenital hydrocephalus in 70 (46.4%), post infectious hydrocephalus in 57 (37.7%), hydrocephalus due to tumor in 22 (14.6%), and post traumatic hydrocephalus in two (1.4%) patients. Among the total number of patients, 85 patients (55.6%) were done as elective cases and 66 patients (44.4%) were done as emergency cases. Complications were encountered in 30 patients (19.87%) during the follow-up of 30 days. Complications occurred between day 1 and day 20 of follow-up with a mean of 9.10 ± 1.69 2SD days. Conclusion VP shunt is the most widely used treatment for HDC, but is predisposed to complications and almost every fifth case of VP shunt comes across with complications. Shunt blockage, infections and abdominal wound-related complications are common earlier complications in pediatric patients with hydrocephalus.

Unilateral approach for bilateral decompression of lumbar spinal stenosis: a minimal invasive surgery.

OBJECTIVE: To assess the feasibility and efficacy of a novel, minimally invasive spinal surgery technique for the correction of lumbar spinal stenosis involving unilateral approach for bilateral decompression. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Neurosurgery Department of PGMI, Lady Reading Hospital, Peshawar, from January to December 2010. METHODOLOGY: A total of 60 patients with lumbar stenosis were randomly assigned to undergo either a conventional laminectomy (30 patients, Group A), or a unilateral approach (30 patients, Group B). Clinical outcomes was measured using the scale of Finneson and Cooper. All the data was collected by using a proforma and different parameters were assessed for a minimum follow-up period of three months. Data was analyzed by descriptive statistics using SPSS software version 17. RESULTS: Adequate decompression was achieved in all patients. Compared with patients in the conventional laminectomy group, patients who received the novel procedure (unilateral approach) had a reduced mean duration of hospital stay, a faster recovery rate and majority of the patients (88.33%) had an excellent to fair operative result according to the Finneson and Cooper scale. Five major complications occurred in all patient groups, 2 patients had unintended dural rent and 2 wound dehiscence each and fifth patient had worsening of symptoms. There was no mortality in the series. CONCLUSION: The ultimate goal of the unilateral approach to treat lumbar spinal stenosis is to achieve adequate decompression of the neural elements. An additional benefit of a minimally invasive approach is adequate preservation of vertebral stability, as it requires only minimal muscle trauma, preservation of supraspinous/intraspinous ligament complex and spinous process, therefore, allows early mobilization. This also shortens the hospital stay, reduces postoperative back pain, and leads to satisfactory outcome.

Endoscopic third ventriculostomy for obstructive hydrocephalus.

OBJECTIVE: To determine the success rate of endoscopic third ventriculostomy (ETV) for treating obstructive hydrocephalus. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: The Neurosurgery Department of PGMI, Lady Reading Hospital, Peshawar, from May 2010 to November 2011. METHODOLOGY: Patients with obstructive hydrocephalus due to aqueductal stenosis, tectal and non-tectal tumour and already shunted patients for obstructive hydrocephalus presented with blocked shunt were included in the study. Patients with congenital hydrocephalus and secondary to meningitis were excluded. Endoscopic third ventriculostomy was performed. Success, complications and mortality was noted. Data was analyzed by descriptive statistics using SPSS software version 17. RESULTS: There were 155 patients including 72 males and 83 females with ratio of 1: 1.33. Success rate was 71%. Indication of surgery was obstructive hydrocephalus due to aqueductal stenosis, posterior fossa tumour, brain stem and CP angle tumour. Complications were seen in 18 patients including mortality in 3 patients. CONCLUSION: ETV is effective, safe and successful procedure in patients with obstructive hydrocephalus. It may be used as replacement procedure of ventriculo-peritoneal shunt as initial line of management in selected patients.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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%). CONCLUSION: 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.

BACKGROUND: 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. METHODS: 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. RESULTS: 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 (range 15-60). 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. CONCLUSION: Although long- term follow-up evaluation needs to verified, the short-term follow-up results suggest a favourable outcome for short-segment instrumentation.