Conus Medullaris Arachnoid Cyst Presenting as Cauda Equina Syndrome.

Intradural arachnoid cysts are a rare cause of spinal cord and nerve root compression. Primarily, they are present in the thoracic region posteriorly. We report a 25-year-old man who had an intradural arachnoid cyst at the level of conus medullaris presenting with cauda equina syndrome, which is very rare.

Surgically treated spinal metastases: Do prognostic scores have a role?

BACKGROUND: The outcome for patients with metastatic disease in spine is difficult to predict. Multiple scoring systems were utilized in this study to determine their effectiveness in predicting long-term prognoses. METHODS: A retrospective analysis of surgically treated patients of spinal metastasis was performed between 2005 and 2016. Data were collected prospectively during which 8 patients were lost to follow-up. Ultimately, data from 63 patients were reviewed. Treatment and prognoses were analyzed utilizing various scoring systems including the SINS, the Tomita, the modified Tokouhashi and Bauer scores. RESULTS: Records of 63 patients, averaging 54 years of age, were analyzed. The Tomita score was applied in 44 patients, a modified Bauer score was studied in 49 patients, while SINS and modified Tokouhashi scores were calculated in all 63 patients. The hazard ratios for the Tomita score were 1, 0.030, 0.622, and 0.272, respectively. The hazard ratios for the modified Bauer scores were 1, 4.663, and 1.622, respectively. The Tokouhashi ratios were 1, 1.656, and 0.501, respectively. Of interest, the Tomita scores provided the highest statistical significance (P = 0.000) followed by the Bauer (P = 0.002) and Tokuhashi scores (P = 0.003). Notably, the SINS score showed no significant correlation in predicting patient survival. CONCLUSION: For evaluating the metastatic spine disease, this study evaluated the prognostic efficacy of four widely used scores: the Tomita, score, the modified Tokouhashi and Bauer scores, and the SINS scores. The Tomita scores provided the highest statistical significance, followed by the Bauer, and Tokuhashi scores, while the SINS score showed no significant correlation in predicting patient survival.

Management of cervical trauma: A Brief review.

Cervical injury is not uncommon in any trauma, especially in road traffic accident. A standard approach, towards, transport, workup, and management is required for best outcomes, and decrease morbidity. We tried to review the recent literature and briefly discuss the management protocols concluded that in our setting, emergency ambulance personnel and Emergency Room doctors should be trained in dealing with all kinds of cervical spine trauma, they should be aware of recent guidelines and should refrain from using steroids routinely. By following guidelines, large numbers of cervical spine injury patients can benefit.

Preventive Gabapentin versus Pregabalin to Decrease Postoperative Pain after Lumbar Microdiscectomy: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. PURPOSE: The purpose of this study was to compare pregabalin and gabapentin for mean postoperative visual analog score (VAS) for pain in patients undergoing single-level lumbar microdiscectomy for intervertebral disc prolapse at a tertiary care hospital. OVERVIEW OF LITERATURE: Pregabalin has a superior pharmacokinetic profile and analgesic effect at lower doses than gabapentin; however, analgesic efficacy must be established during the perioperative period after lumbar spine surgery. METHODS: This randomized controlled trial was carried out at our institute from February to October 2011 on 78 patients, with 39 participants in each study group. Patients undergoing lumbar microdiscectomy were randomized to group A (gabapentin) or group B (pregabalin) and started on trial medicines one week before surgery. The VAS for pain was recorded at 24 hours and one week postoperatively. RESULTS: Both groups had similar baseline variables, with mean ages of 42 and 39 years in groups A and B, respectively, and a majority of male patients in each group. The mean VAS values for pain at 24 hours for gabapentin vs. pregabalin were comparable (1.97±0.84 vs. 1.6±0.87, respectively; p=0.087) as were the results at one week after surgery (0.27±0.45 vs. 0.3±0.46, respectively; p=0.79). None of the patients required additional analgesia postoperatively. After adjusting for age and sex, the VAS value for group B patients was 0.028 points lower than for group A patients, but this difference was not statistically significant (p=0.817, R2=0.018). CONCLUSIONS: Pregabalin is equivalent to gabapentin for the relief of postoperative pain at a lower dose in patients undergoing lumbar microdiscectomy. Therefore, other factors, such as dose, frequency, cost, pharmacokinetics, and side effects of these medicines, should be taken into account whenever it is prescribed.

Neurosurgery training in Pakistan: Follow-up survey and critical analysis of National Training Programmes.

This cross-sectional nation-wide survey was planned to assess the current status of neurosurgery residency training in Pakistan and to compare it with the results of a previous study. The duration of study was from July to December 2015. It comprised of neurosurgery trainees enrolled with the College of Physicians and Surgeons of Pakistan (CPSP). In this study, 43 trainees from 13 centres were included. The mean duration of training acquired by participants was 2.8±1.9 years. The mean work hours were 73.8±21.9 per week. Moreover, 28(65%) trainees had access to at least one neurosurgery journal while 29(67%) did not have any indexed publication. Besides, 2(15.4%) centres did not have internet facility and more than half did not have a regular morbidity and mortality meeting. Training facilities were highly variable in different institutes. When compared with previous study, little improvement occurred during the previous six years. We recommend a uniform academic curriculum and standardisation of training facilities among different institutes.

Variation in Outcome in Tethered Cord Syndrome.

STUDY DESIGN: Fifty patients surgically treated for tethered cord syndrome (TCS) were retrospectively studied at Liaquat National Hospital, Karachi from 2010 until 2014. PURPOSE: To assess the common presentations of TCS in our part of the world and the surgical outcome of the different presentations. OVERVIEW OF LITERATURE: TCS is a stretch-induced functional disorder of the spinal cord with its caudal part anchored by an inelastic structure, which results in characteristic symptoms and signs. Due to the variety of lesions and clinical presentations and the absence of high-quality clinical outcome data, the decision regarding treatment is difficult. METHODS: Fifty consecutive patients with TCS were reviewed retrospectively with a follow-up period of 12-48 months. The majority of the patients were 0-15 years of age with the mean age of 4 years. The presenting complaints and the associated pathologies were documented, and the patients were assessed using the new Karachi TCS severity scale for clinical assessment. RESULTS: Eighty five percent of the patients with thickened filum terminale improved. Sixty six percent of the patients with diastematomyelia, 60% with lipoma and only 46% with myelomeningocele showed clinical improvement postoperatively. Sixty two percent of the patients who presented with paraperesis improved following surgery while 37% remained stable and only one patient deteriorated. Back and leg pain improved in 93% of patients and 50% of patients with urinary impairment improved. CONCLUSIONS: Outcome of patients with TCS varies according to pathology and severity of symptoms. Diastematomyelia and thickened filum had the best outcome. The Karachi TCS severity scale is a valid tool for future studies.

Use of Levetiracetam in Prophylaxis of Early Post-Traumatic Seizures.

AIM: Traumatic brain injury is one of the leading causes of mortality and morbidity worldwide. The role of prophylactic anti-epileptic drugs has been established. Phenytoin used traditionally for this purpose carries a burden of adverse reactions and cumbersome need of monitoring and maintaining levels in serum. Therefore, as the evidence on levetiracetam, emerged part of neurosurgery section started using this drug for seizure prophylaxis after early loading with phenytoin. So we decided to assess the use of enteral levetiracetam in prophylaxis of early post-traumatic seizures. MATERIAL AND METHODS: This was a retrospective cohort study done at the department of neurosurgery of Aga Khan University in Karachi from July 2010 to March 2011. Charts of patients who were started on levetiracetam enterally were reviewed and followed for occurrence of clinical seizures within one week of trauma. The results were then compared to the group of patients treated prophylactically with phenytoin alone over the same time period. RESULTS: The study included 50 patients in each group. Both groups were comparable in terms of demographics and baseline characteristics. However, 2 patients in each group suffered from clinical seizures with a non-significant p value. CONCLUSION: Enteral levetiracetam after initial phenytoin loading is a viable option in the armamentarium of anti-epileptic drugs. Further larger prospective studies are required to improve the evidence.

Predicting outcomes of decompressive craniectomy: use of Rotterdam Computed Tomography Classification and Marshall Classification.

BACKGROUND: Data on the evaluation of the Rotterdam Computed Tomography Classification (RCTS) as a predictor of outcomes in patients undergoing decompressive craniectomy (DC) for trauma is limited and lacks clarity. OBJECTIVE: To explore the role of RCTS in predicting unfavourable outcomes, including mortality in patients undergoing DC for head trauma. METHODS: This was an observational cohort study conducted from 1 January 2009 to 31 March 2013. CT scans of adults with head trauma prior to emergency DC were scored according to RCTS. A receiver operating characteristic curve analysis was performed to identify the optimal cut-off RCTS for predicting unfavourable outcomes [Glasgow outcome scale (GOS) = 1-3]. Binary logistic regression analysis was performed to evaluate the relationship between RCTS and unfavourable outcomes including mortality. RESULTS: One hundred ninety-seven patients (mean age: 31.4 ± 18.7 years) were included in the study. Mean Glasgow coma score at presentation was 8.1 ± 3.6. RCTS was negatively correlated with GOS (r = -0.370; p < 0.001). The area under the curve was 0.687 (95% CI: 0.595-0.779; p < 0.001) and 0.666 (95% CI: 0.589-0.742; p < 0.001) for mortality and unfavourable outcomes, respectively. RCTS independently predicted both mortality (adjusted odds ratio for RCTS >3 compared with RCTS ≤3: 2.792, 95% CI: 1.235-6.311) and other unfavourable outcomes (adjusted odds ratio for RCTS >3 compared with RCTS ≤3: 2.063, 95% CI: 1.056-4.031). CONCLUSION: RCTS is an independent predictor of unfavourable outcomes and mortality among patients undergoing emergency DC.

Computed Tomography-Guided Biopsy for Potts Disease: An Institutional Experience from an Endemic Developing Country.

STUDY DESIGN: A retrospective chart review. PURPOSE: In endemic resource poor countries like Pakistan, most patients are diagnosed and treated for Potts disease on clinical and radiological grounds without a routine biopsy. The purpose of this study was to evaluate the use and effect of computed tomography (CT)-guided biopsy in the management of Potts disease since the technique is becoming increasingly available. OVERVIEW OF LITERATURE: CT-guided biopsy of spinal lesions is routinely performed. Literature on the utility of the technique in endemic resource poor countries is little. METHODS: This study was conducted at the Neurosurgery section of Aga Khan University Hospital Karachi. All the patients with suspected Potts disease who underwent CT-guided biopsy during the 7 year period from 2007 to 2013 were included in this study. Details of the procedure, histopathology and microbiology were recorded. RESULTS: One hundred and seventy-eight patients were treated for suspected Potts disease during the study period. CT-guided biopsies of the spinal lesions were performed in 91 patients (51.12%). Of the 91 procedures, 22 (24.2%) were inconclusive because of inadequate sample (10), normal tissue (6) or reactive tissue (6). Sixty-nine biopsies were positive (75.8%). Granulomatous inflammation was seen in 58 patients (84.05%), positive acid-fast bacillus (AFB) smear in 4 (5.7%) and positive AFB culture in 12 patients (17.3%). All 91 cases in which CT-guided biopsy was performed responded positively to antituberculosis therapy (ATT). CONCLUSIONS: 75.8% of the specimens yielded positive diagnoses. Granulomatous inflammation on histopathology was the commonest diagnostic feature. In this series, the rates of positive AFB smear and culture were low compared to previous literature.

Confusing presentation of chaetomium brain abscess.

We put forth the case of a young immunocompetent female who presented with fever and left basal ganglia bleed secondary to vasculitis. After 2 weeks of prednisolone therapy, she continued to deteriorate. MRI scan revealed enhancement of previous hematoma, pus was aspirated surgically and fungal culture grew Chaetomium.

Cranioplasty after decompressive craniectomy: An institutional audit and analysis of factors related to complications.

BACKGROUND: Although a relatively simple procedure, cranioplasties have been associated with high complication rates. Keeping this in perspective, we aimed to determine the factors associated with immediate and long-term complications of cranioplasties at our institution. METHODS: A retrospective review of patient records was carried out for patients having undergone reconstructive cranioplasties at our institution during the last 10 years (2001-2010). All case notes, records, and investigations were reviewed and the data were recorded in a predesigned questionnaire. Complications were recorded along with existing comorbids and measures taken for their prevention and management. Univariate and multivariate logistic regression analysis was performed to determine possible predictors of complications. RESULTS: A total of 96 patients with a mean age of 33 + 15 years were included in the study. Of the sample, 76% (n = 73) had no comorbids. The leading primary pathology was blunt traumatic brain injuries in 46% (n = 44), followed by cerebrovascular incidents in 24% (n = 23), penetrating traumatic brain injuries in 12% (n = 11), and tumors in 10% (n = 10) of cases, with 41% (n = 39) of patients requiring multiple craniotomies. In a mean follow-up of 386 ± 615 days, complications were noted in 36.5% (n = 35) of the patients. Twenty six percent of patients (n = 25) had minor complications which included breakthrough seizures (15.6%, n = 15), subgaleal collections (3.1%, n = 3), and superficial wound infections (3.1%, n = 3), whereas major complications (10.4% n = 10) included hydrocephalus (3.1%, n = 3), transient neurological deficits (3.1%, n = 3), and osteomyelitis (2.1%, n = 2). Univariate and multivariate analysis revealed External Ventricular Drain (EVD) placement and parietal flaps to be associated with complications. This could be explained by the fact that the patients requiring EVD usually have relatively severe head injuries, increasing the possibility of hydrocephalus. CONCLUSION: We have found a higher risk of complications of cranioplasty in patients who had EVD placement and removal prior to their constructive surgery. We however did not find any association between risks of complications in any other studied variable. We also did not find any association between intraoperative placement of subgaleal drains and postoperative risk of subgaleal fluid collections. Overall, our results are comparable with other reported series on cranioplasties.

Emergency department predictors of tracheostomy in patients with isolated traumatic brain injury requiring emergency cranial decompression.

OBJECT: Patients with severe traumatic brain injury (TBI) frequently require a tracheostomy for prolonged mechanical ventilation and/or pulmonary toilet. It is now proven that the earlier the procedure is done, the more beneficial it is to the patient. The present study was carried out to determine if the requirement of a tracheostomy can be predicted on arrival of a patient to the emergency department. The prediction can potentially aid in combining the procedure with cranial decompression. In this study, the authors' aim was to determine the emergency department predictors of tracheostomy in patients with isolated TBI requiring emergency cranial decompression. METHODS: The authors performed a retrospective chart review of all patients who underwent surgery for isolated TBI and required more than 4 days of mechanical ventilation. Multivariate logistic regression analysis was used for predictive indicators. RESULTS: In patients with isolated severe TBI, a patient age of 31-50 years, the presence of preexisting medical comorbid conditions, a delay in emergency department arrival exceeding 1.5 hours, an abnormal pupil response on arrival, and a preoperative neurological worsening during hospital stay were independent predictors of the requirement for tracheostomy. These findings were validated in a small cohort of patients and were found to be significant. CONCLUSIONS: Requirement of a tracheostomy can be predicted in patients with severe TBI on arrival to the emergency department. These results were validated in a small cohort of patients, and it was found that the positive predictive value of requirement of tracheostomy was directly proportional to the number of predictors present. Larger prospective studies with appropriate control groups are further recommended to validate the authors' findings.

Cranial reconstruction after decompressive craniectomy: prediction of complications using fuzzy logic.

INTRODUCTION: Cranial reconstruction after decompressive craniectomy (DC) has been shown to be associated with a relatively high complication rate (16.4%-34%) compared with standard neurosurgical procedures (2%-5%). Most studies that have previously attempted to formulate a multivariate model for identifying factors predictive of postoperative complications of cranioplasty either were unsuccessful or yielded conflicting results. Therefore, fuzzy logic-based fuzzy inference system (FIS), which has proven to be a useful tool for risk prediction in medical and surgical conditions, was used in this study to identify predictors of complications of cranioplasty. METHODS: A retrospective chart review of all the patients who underwent DC followed by elective cranioplasty at Aga Khan University Hospital, during a 10-year period (2000-2010), was carried out to collect data on 24 carefully selected preoperative variables or inputs. The proposed FIS had 24 inputs, 3 outputs, and a set of 7 fuzzy-based rules. All inputs were assigned degrees of membership, and complications were further divided into "severe," "minor," and "least" output classes with each of them representing 2 membership functions: "less" and "more." For each set of inputs, a specific portion of the hypersurface was masked out. The centroid of this subsurface represented the defuzzified output corresponding to 1 percentage value for each output. The maximum of these outputs for each of the 3 output classes was selected to be the final output class. Each output class was compared to the actual outcome of patients, and positive predictive value, negative predictive value, sensitivity, and specificity of FIS for predicting complications were calculated. RESULTS: A total of 89 patients (mean [SD] age, 33.1 [15.0] y; male-to-female ratio, 3:1) were included in the study. The common postoperative complications included seizures (14.6%), cerebrospinal fluid leak (4.5%), neurologic deficits (3.4%), hydrocephalus (3.4%), superficial wound infection (3.4%), and osteomyelitis (2.2%). The FIS correctly identified all 7 patients who developed severe complications after cranioplasty (true positives) and all 82 patients who did not develop severe complications (true negatives). Thus, the FIS has a sensitivity and specificity of 100% in predicting severe complications. CONCLUSIONS: Our study shows that the procedure of cranioplasty is associated with a high complication rate and that FIS has a 100% sensitivity and specificity in predicting severe complications after cranioplasty. It will prove to be an invaluable tool for clinicians once the results are validated by a similar prospective study with a larger sample size.