Surgical Outcome of Intradural Spinal Tumors.

Results of 63 surgically treated intradural spinal tumors between the period of October 2003 and December 2014 at Bangabandhu Sheikh Mujib Medical University (BSMMU) and in our private settings, Dhaka, were analyzed retrospectively. There were 33 males, 30 females with an average age of 52.4 years (13-70 years) and followed up for at least a year. The preoperative symptom with duration, tumors location and intradural space occupancy and the histopathological diagnosis were analyzed. Pain was evaluated by the visual analogue scale (VAS) and the neurologic function was assessed by Nurick's grade. The tumors were located as, thoracic (n=32, 50.79%), lumbar (n=16, 25.39%), cervical (n=05, 07.93%), and junctional (n=10, 15.87%, CervicoThoracic-01, Thoracolumbar-09). The histopathological diagnosis included schwannoma (n=30, 47.7%), meningiomas (n=14, 22.3%), neurofibroma, arachnoid cyst and myxopapillary ependymoma (n=03, 04.76%) each and paraganglioma (n=01, 01.59%). Among the intramedullary tumors, ependymoma (n=03, 04.76%), astrocytoma and epidermoid cyst (n=02, 03.17%), haemangioblastoma, paraganglioma and cavernous haemangioma (n=01, 01.59%) each. The VAS score was reduced in all cases from 8.0±1.2 to 1.2±0.8 (p<0.003) and the Nurick's grade was improved in all cases from 3.0±1.3 to 1.0±0.0 (p<0.005). The preoperative neurological deficit improved within 8 postoperative weeks in most cases and within 1 postoperative year in all cases. Complications included cerebrospinal fluid leakage, parasthesia and further neurological deterioration (Astrocytoma) (n=02, 03.17%) and dependant bedsore and recurrence (Ependymoma) (n=01, 01.59%). Aggressive surgical excision potentially minimizes neurologic morbidity and improved outcome except intramedullary tumors where initial treatment consists of maximum safe surgical resection or biopsy.

Early Outcome of Repair of Symptomatic Pars Defect by Intra-Laminar Screws and Bone Graft.

Out of wide range of surgical techniques direct repair techniques are emphasized to avoid fusion related complications in pars defects. To assess the clinical, functional and radiological outcome of direct operative repair of pars defects by intra-laminar screws and bone graft, this retrospective study was done in Bangabandhu Sheikh Mujib Medical University and in our private settings, within the period of July 2005 to December 2012. Records of 12 patients (age range, 21-35 years) with symptomatic pars defect, 07 men and 05 women (mean 28 years) who underwent direct pars repair with intralaminar screws and bone graft were reviewed. The surgical time, intra-operative blood loss, post operative hospital stay and time to achieve union was recorded. Self evaluated back pain [using Visual Analogue Score (VAS)] and disability [using Oswestry disability (ODI) questionnaire] was analyzed. Clinical outcome was assessed [using Modified Prolo Scale], Radiological fusion (using Shin criteria), restoration of total lumbar lordosis (TLL) and overall functional outcome [using Odom's Criteria] was calculated. Chi-squared test and paired-t test were used for statistical analysis using SPSS. The VAS, ODI and clinical outcome had significant (p<0.05) improvement as had the radiological fusion and TLL. Overall satisfactory outcome was achieved in 91.67% cases. Despite of no intra-operative or post-operative complications, pseudarthrosis developed in 01 case which could be managed conservatively. Direct repair of spondylitic defect with intra-laminar screws and bonegraft is satisfactory in properly selected cases.

Outcome of modified Bristow-Laterjet procedure in post-traumatic recurrent anterior shoulder dislocation in young population.

Anterior shoulder dislocation (ASD) is a common injury of young population which may progress to recurrent episodes. The treatment is initially conservative but surgery is indicated when it fails. Out of more than 150 techniques, modified Bristow-Latarjet procedure has become most favorable even to arthroscopic techniques. We have intended to retrospectively assess the outcome of it in post-traumatic recurrent ASD of young non-athletes, performed at our different private settings between January 2007 and July 2012; which included 15 male patients of 20-39 years with minimum 2 years follow up. Clinical, functional, radiological and overall outcome status were evaluated. There was significant improvement of shoulder stability (p<0.05, chi-square test) despite significant deterioration (p<0.05, paired t-test) of external rotation (21.67°±00.61° loss). The patient self assessed pain and instability had highly significant (p<0.001, paired t-test) and all components of activities of daily living (except above shoulder weight carrying and overhead throwing) had significant improvement (p<0.05, paired t-test). Despite of intra-operative difficulties, radiological transplant errors (33.33%) and post-operative complications (06.67%), overall satisfactory outcome (86.67%) had been significant (p<0.05, chi-square test).

Comparison of arthroscopic anterior cruciate ligament reconstruction by bone-patellar tendon-bone graft with or without using interferential screw in general population.

Rupture of the Anterior Cruciate Ligament (ACL) is common, resulting reduced quality of life, increasing the meniscal injury risk, knee instability and early degenerative joint disease. Bone-Patellar Tendon-Bone (BPTB) became the gold standard surgery where conservative management failed. Adding interferential screw provides rigid fixation which is important for early accelerated rehabilitation program in athletes but we have carried out this prospective interventional study in Bangabandhu Sheikh Mujib Medical University (BSMMU) and our private settings from January 2007 to December 2011 to assess whether interferential screws provide any clinical and functional advantage in general population. Sixty six male patients of 21-40 years age, with ACL deficient knees were reconstructed with BPTB graft where 40 cases were augmented by interferential screws and 26 cases without and followed up for minimum 2 years. The clinical and functional outcome (by Lysholm Knee Scoring), post-operative knee stability (by clinical tests) and complications were assessed and recorded. There was significant (p<0.05, paired 't' test) improvement of knee function (limp, walking, stair climbing, squatting, thigh atrophy) in both groups but no significant difference between them (p>0.05, chi squared test) regarding clinical, functional outcome and knee stability. The complications were insignificant (p>0.05, chi squared test) in both groups but there were few cases of screw related complications with augmentation and pronounced anterior knee laxity without it. So, ACL reconstruction by BPTB grafts with or without augmentation results consistent and comparable outcome in general population.

Outcome of symptomatic upper lumbar disc herniation.

"Upper" lumbar disc herniations (LDH) are different from the "lower" and possess increased chance of neural compromise and cauda equina syndrome that necessitates operative management despite of contradictory surgical outcome. We underwent the study to assess the clinical and functional outcome of symptomatic upper LDH surgery from July 2003 to June 2012 in BSMMU, Dhaka, Bangladesh. The records of 123 patients (age range, 30-69 years), 56 men and 67 women (mean 52 years) having upper lumbar discectomy were reviewed. The surgical time, intra-operative blood loss, self evaluated back pain and thigh and/or groin pain status [using Visual Analogue Score (VAS)] and the disability status [using Oswestry disability (ODI) questionnaire] was analyzed. Radiological stability (using Posner's criteria), functional outcome [using Japanese Orthopaedic Association (JOA) Score] and overall outcome (using MacNab`s criteria), was calculated. Chi-squared test and z-test using SPSS revealed mean operative time and mean blood loss had no significant (p>0.05) difference. Pain, sensory, motor and reflex status as well as VAS, ODI and all the components of JOA questionnaire had significant (p<0.05) improvement. In spite of intra-operative complications in 20.32% cases, overall satisfactory outcome was achieved in 83.74% cases. The postoperative complications (08.13%) could be managed conservatively. However, carefully decided surgical alternatives resulted in satisfactory clinical and functional outcome in upper LDH surgery.

Comparison between arthroscopic partial and total meniscectomy of medial meniscus in non-professional athletes.

Large number of patients suffers from medial meniscus injury during athletic activities despite of not being involved in professional sports. Our goal was to compare clinical and functional outcome of arthroscopic partial meniscectomy with results of arthroscopic total meniscectomy of the medial meniscus in these non-professional athletes. The prospective interventional study was carried out in a five years period from January 2007 to December 2011. According to predefined inclusion and exclusion criteria 109 patients were selected and underwent surgery but 29 patients lost from follow-up. Results of 40 cases with Arthroscopic partial meniscectomy (Group-I) and 40 cases with arthroscopic total meniscectomy (Group-II) were analyzed. There were 75 male patients and the predominant age group was 21-30 years. Patients were followed up for a range of 36-60 months. Standard questionnaires of Visual Analogue Score (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner-Lysholm Knee Score (TLKS) and Tapper and Hoover criteria was used to assess and compare the outcomes. Radiological assessment was done to note any changes. Students were sufferers in majority cases and bucket handle tear had been the commonest type. Significant difference of clinical, functional and radiological outcome was observed at minimum 3 years follow up. One case needed revision in Group-II and the infection rates were insignificant. Arthroscopic partial meniscectomy is significantly better method for surgical management of medial meniscus injuries.

Transforaminal lumbar interbody fusion in symptomatic low-grade isthmic spondylolisthesis.

Isthmic spondylolisthesis (IS) is the most common spondylolytic disorders and one of the most common causes of low back pain and sciatica in adolescents and adults. Although the initial management is conservative, surgery is often the ultimate solution. Interbody fusion has been found superior and replaced the gold standard postero-lateral fusion. Transforaminal Lumbar Interbody Fusion (TLIF) has been associated with fewer complications and has become the choice of surgery. This study was done to evaluate the clinical, radiological and functional outcome of TLIF in Low Grade Isthmic Spondylolisthesis (LGIS). The clinical records of 46 consecutive patients within the age range of 31 to 60 years, who had symptomatic unstable Low Grade Isthmic Spondylolisthesis (LGIS) with or without unilateral radiculopathy in Bangabandhu Sheik Mujib Medical University (BSMMU) and private settings, from April 2007 to March 2012 were reviewed with 2 year completed follow-up. Patients were evaluated for pain by Visual Analogue Score (VAS), Disability by Oswestry Disability Index (ODI), radiological fusion by Brantigan and Steffee criteria, reduction of listhesis by Taillard's method and the overall functional outcome by the Macnab's criteria. Pain (Low back and leg), disability, neurological status had highly significant (p<0.001, paired t test) improvement. Forty two (91.30%) cases achieved satisfactory radiological fusion with overall 30% reduction of slip. Satisfactory outcome was reached in 45(97.83%) cases. Transforaminal Lumbar Interbody Fusion results in significant improvement of clinical, radiological and functional debility of symptomatic LGIS in adults.

Evaluation of the outcome of replacement hemiarthroplasty by uncemented bipolar prosthesis in displaced fracture neck femur.

Despite continued discussion regarding the treatment of displaced femoral neck fractures, controversies continue regarding their optimal treatment, including the choice of implant and fixation method. Hemiarthroplasty is one of the option which eliminate concerns about fixation failure, nonunion, and avascular necrosis and has become the choice of surgery among the aged >60. This prospective interventional study was carried out on 28 cases at the Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), from July 2009 to April 2012 to evaluate cementless, bipolar prosthesis among the active elderly patients. All subjects were evaluated with regard to postoperative clinical, functional and activity outcome (Modified Harris Hip Scoring and Hip Outcome Scoring), intra and post operative complications. One case was dropped from follow up and 22(81.48%) patients were considered to have satisfactory outcome after statistical analysis by chi-square test on at least 12 months follow up records. Although prosthetic stem valgus and periprosthetic fracture developed in 02 cases and 01 patient had sunken prosthesis, uncemented bipolar hemiarthroplasty can give significantly good functional outcomes with minimal complications for displaced intracapsular femoral neck fracture in active elderly patients.

Instrumented posterior lumbar interbody fusion (PLIF) with interbody fusion device (Cage) in degenerative disc disease (DDD): 3 years outcome.

This prospective interventional study carried out at Bangabandhu Sheikh Mujib Medical University and a private hospital in Dhaka, Bangladesh during the period from October 2003 to September 2011. Surgical treatment of degenerative disc disease (DDD) should aim to re-expand the interbody space and stabilize until fusion is complete. The present study conducted to find out the efficacy of using interbody fusion device (Cage) to achieve interbody space re-expansion and fusion in surgical management of DDD. We have performed the interventional study on 53 patients, 42 female and 11 male, with age between 40 to 67 years. All the patients were followed up for 36 to 60 months (average 48 months). Forty seven patients were with spondylolisthesis and 06 with desiccated disc. All subjects were evaluated with regard to immediate and long term complications, radiological fusion and interbody space re-expansion and maintenance. The clinical outcome (pain and disability) was scored by standard pre and postoperative questionnaires. Intrusion, extrusion and migration of the interbody fusion cage were also assessed. Forty seven patients were considered to have satisfactory outcome in at least 36 months follow up. Pseudoarthrosis developed in 04 cases and 06 patients developed complications. In this series posterior lumbar interbody fusion (PLIF) with interbody cage and instrumentation in DDD showed significant fusion rate and maintenance of interbody space. Satisfactory outcome observed in 88.68% cases.

Relationship between physical work load and lumbar disc herniation.

Lumbar disc herniation (LDH) is a disabling problem. This retrospective case control study was done to evaluate the possible relevance of physical work load with Lumbar Disc Herniation. We have performed this study in the Spinal Surgery Unit of Department of Orthopaedic Surgery at BSMMU, Dhaka from July 2007 to June 2010 where 200 cases with Lumbar Disc Herniation and 200 control subjects matched by age, gender and area of residence were taken and analyzed. Chi-square test was computed for sex, area of residence, type of physical work and effort at work, whereas Odds ratio was computed for physical work load, stress at work and daily working period. The highest odds ratio (OR) was with the physical work load (OR: 03.48, CI: 01.84-06.59), hard work (OR: 03.14, CI: 01.74-05.65) and working period of >8 hours (OR: 01.34, CI: 0.75-02.38). Odds ratio for heavy load carrying at work was 03.48 and less job satisfaction or stress at work was 02.45. There was a statistically significant positive association between cumulative exposure of physical work load and lumbar disc herniation indicating an increased occurrence of herniation in heavy physical work load and occupation requiring harder efforts.

Single space transforaminal lumbar interbody fusion in spondylolisthesis: initial experience of 30 cases.

Spondylolisthesis in adults is characterized by the loss of disc height across the affected segment with sagital translation. The goal of stabilizing the spine is accomplished by fusion. Transforaminal approach for lumbar interbody fusion is a very good approach and reduces the complications associated with traditional posterior approach. It has been reported to be safe and effective in the treatment of spondylolisthesis. It has done to assess the functional outcome of Transforaminal Lumbar Interbody Fusion (TLIF) in spondylolisthesis. This prospective interventional study was performed from July 2008 to June 2011 included 30 patients (male 07, female 23), within a age range of 30-59 years. Nineteen cases were lytic, 08 cases were degenerative, 02 were post-traumatic and 01 dysplastic variety of spondylolisthesis. Follow up ranged from 12 to 24 months and outcome assessed by VAS and ODI regarding pain and disability. Achievement of fusion and complications were documented accordingly. Statistical analysis was done by unpaired t-test and chi-squared test in appropriate instances. We included twenty One (70.00%) patient had Grade-II Spondylolisthesis and L4 over L5 had been the commonest level (53.33%) involved. Pain and disability improved significantly and 22 (73.33%) patients returned to their previous level of activity. One (03.33%) patient developed superficial wound infection and 01 (03.33%) had persistent low back pain. All patients had neurological improvement. We concluded that Transforaminal Lumbar Interbody Fusion is an effective alternative surgical procedure for the treatment of spondylolisthesis. Overall outcome is satisfactory in 93.33% cases.

Anterior cervical discectomy, fusion and stabilization by plate and screw--early experience.

Anterior cervical plating is commonly performed to stabilize anterior cervical fusion. The aim of the study was to evaluate the clinical and functional outcome, radiological fusion and operative complications in cases of cervical spondylotic myelopathy and radiculopathy who underwent Anterior Cervical Discectomy and Fusion (ACDF) by autograft and stabilized with plate and screw. We evaluated 16 consecutive patients (M: F = 10:6) from January 2008 to December 2010 in Bangabandhu Sheikh Mujib Medical University (BSMMU) and different private hospitals in Dhaka, in cases where adequate conservative treatment failed. Single level ACDF by autograft and stabilization by plate and screw was done in 10 patients and 06 patients had two levels fusion. The mean follow up period was 18 months. The patients improved significantly (p < 0.05) and the recovery rate was 87.50%. All patients showed radiological fusion (p < 0.001). There was no hardware failure, graft extrusion or plate breakage. ACDF with plate and screw is fairly safe and effective therapy for cervical disc degeneration leading to myelo-radiculopathy where major post operative complications are uncommon.

Evaluation of the results of posterior decompression, posterolateral fusion and stabilization by pedicle screw and rod in traumatic thoracolumbar fractures.

This study is to evaluate the clinical and radiological success of posterior decompression, posterolateral fusion and stabilization by pedicle screw and rod in the management of traumatic thoracolumbar fractures. It is a prospective interventional study which is carried out in Bangabandhu Sheikh Mujib Medical University and different private hospitals in Dhaka city from January 2008 to December 2010. Total 16 patients were selected according to the inclusion and exclusion criteria. There were 10 male patients and 06 female within a age range of 21-40 years. Mean age was 33.32 years. Total 08 cases involved L1, 03 cases involved at D12, 02 cases involved at D1, and at L2 each whereas 01 case at L3. Total 10 cases were of compression fracture and remainder 06 burst fractures. Ten (10) patients presented with paraparesis, 05 patients with incomplete paraplegia and 01 patient with complete paraplegia. All the patients were followed up for minimum 1 year. Patients with paraparesis fully recovered neurologically and could walk without support. All the 05 patients with incomplete paraplegia also recovered fully except 01 which gained partial improvement and walks with aids. One patient with complete paraplegia remained unchanged. Our results show that posterior decompression posterolateral fusion and stabilization by pedicle screw and rod provides a safe and effective surgical option for management of traumatic thoracolumbar fractures.

Some aspects of psychiatric morbidity in the out-patient population of a general hospital.

A preliminary report on certain aspects of psychiatric morbidity in persons attending the medical out-patients department of the Institute of Post-graduate Medicine, Dacca, have been presented. Out of 652 cases who have been interviewed, 31% had purely psychogenic conditions, 45% were suffering from purely organic diseases and 14.8% complained of symptoms of both organic and psychogenic features. No apparent underlying aetiology have been detected in 8.6% of cases. Of the psychogenic group, neurotic disorders comprised the largest number in the sample; anxiety state and sexual neurosis in males were the commonest neurotic disorders. When the mixed groups are included, 44% of males and 49.8% of females had symptoms which were either purely psychogenic in nature or had conspicuous psychogenic component. Reason for such a high percentage of psychogenic component has been discussed. Most of the patients attending the out-patient department were within the age of 21 to 40 years. Attendance in the number of older age persons were less in the psychogenic group than with organic conditions. Further, in females a significant difference was observed between psychogenic and organic group patients above and below the age of 40 years. Patients younger than 40 years were more in purely psychogenic group compared to organic conditions. Most of the patients have been found to be married both in psychogenic and organic group. However, there was significant difference in attendance rate of single males in the psychogenic group were somewhat over-represented in the sample in comparison to purely organic group. There was no relation of marital states in cases of females.