The diagnostic accuracy of straight leg raise test in patients more than 60 years of age suffering lumbar disk herniation with low back pain and sciatica.

Objective: To determine the diagnostic accuracy of the SLR test in elderly patients suffering from lumbar disk herniation with sciatica and low back pain, using magnetic resonance imaging (MRI) as the gold standard. Materials and Methods: A cross-sectional study was conducted at Jinnah Postgraduate Medical Center and a total of 120 patients, above 60 years of age, with symptomatic lumbar disk herniation were enrolled. SLR test was performed and the results recorded. MRI of the lumbar spine was undertaken for confirmation of disk herniation. Results: The sensitivity of the SLR test in patients 60 years and older is 33.3%. A decrease in the diagnostic accuracy of the SLR test with an increment in age was also noted. Conclusion: It was found that with an increment in age, there is a steady decline in the diagnostic accuracy of SLR Test.

Comparison of the accuracy of intraoperative lateral fluoroscopy versus postoperative computed tomography in spinal fusions.

Background: This study compared the accuracy of intraoperative lateral fluoroscopic images versus postoperative computed tomography (CT) 3D studies in the treatment of thoracolumbar spinal fusions. Methods: In a tertiary care hospital (study duration 6 months), we compared the use of lateral fluoroscopic images with the postoperative CT scans in 64 patients with thoracic or lumbar fractures undergoing spinal fusions. Results: Out of the 64 patients, 61% were lumbar followed by 39% thoracic fractures. In the lumbar spine, the accuracy of screw placement utilizing lateral fluoroscopy versus postoperative CT 3D was 97.4%, while in thoracic spine, accuracy was reduced to 84.4%. Of the 64 patients, just 4 (6.2%) patients demonstrated lateral pedicle cortex penetration, 1 (1.5%) patient had a medial pedicle cortex breach, while none exhibited anterior vertebral body cortex penetration. Conclusion: This study documented the efficacy of lateral fluoroscopy in intraoperative thoracic and lumbar spinal fixation as confirmed by postoperative CT 3D studies. These findings support the continued use of fluoroscopy rather than CT intraoperatively to lower the risk of radiation exposure to both patients and surgeons.

Outcome of head injury in motorbike riders.

Objective: To determine the impact of helmet wearing on traumatic brain injury. Methods: We analyzed 400 cases of traumatic brain injury (TBI) in motorbike riders with and without helmet, from July 2017 to December 2020 presenting to the neurosurgery department at Jinnah Postgraduate Medical Center (JPMC), Karachi, Pakistan. The medical records were analyzed for CT scan findings, length of hospital stay, complications (mortality and disability), Glasgow Coma Scale (GCS) and Glasgow outcome score (GOS) at time of discharge. Result: A total of 400 patients with head injury due to motorbike accidents were included and all were male patients. They were equally divided into two groups, 200 in Group-A (with helmet) and 200 in Group-B (without helmet). Majority of the unhelmeted patients i.e. 102 (51%), needed admission in the Intensive Care Unit (ICU) compared to 70 (35%) in helmeted. When comparing non-helmeted patients to helmeted patients, the total median length of hospital stay was greater among non-helmeted patients (10 vs 05 days). Mortality was higher among non-helmeted patients seen in 50 (25%) as compared to 14 (7%) in helmeted patients. Overall, the good outcome was observed in 119 (59.5%) patients in Group-A as compared to70 (35%) patients in Group-B while 81 (40.5%) showed bad outcome in Group-A and 130 (64%) in Group-B. The failure to wear a helmet was found to be strongly linked with abnormal neuroimaging more complications, poor outcome and lower GCS on discharge as compared to patients using helmet. Conclusion: Lack of helmet use is linked to abnormal brain imaging, more complications, and a longer stay in the hospital after a head injury.

Ventriculoperitoneal Shunt Surgery for Hydrocephalus: One of the Common Neurosurgical Procedures and Its Related Problems.

Objective This study was conducted to assess the outcome in patients with hydrocephalus who underwent ventriculoperitoneal (VP) shunt surgery. Methods This retrospective study was conducted at the neurosurgery department of a tertiary care hospital. The time frame was three years and five months from January 2017 to May 2020 with a follow-up of six months. Results This study included 1030 patients, out of whom 64.2% were male and 35.8% were female. While the majority of the patients were more than 11 years of age (466), age did not have any significant impact on the outcome of the ventriculoperitoneal shunt surgery. The most common cause of hydrocephalus was congenital (47.6%). A good outcome was seen in 63.4%, mortality was 10.6%, and complications were identified for 25.8%. The underlying pathology had a significant impact on the outcome in our study (p-value < 0.05) where the congenital cause of hydrocephalus showed a better outcome than any other cause. Conclusion Ventriculoperitoneal shunt is a good way to manage hydrocephalus, but there is always a high risk of complications.

Herniating Intradural Disc at Lumbar L4-L5 Level: A Case Report.

Prolapse of intervertebral disc is a common pathology seen in the neurosurgery field but intradural lumbar disc herniation is a rare entity encountered only during the surgical treatment of prolapse. We present a 30-year-old male who reported lower back pain radiating to the right lower limb for the last 2.5 years. The pain started after a brief history of weight lifting. There were no associated motor or sensory deficits. The magnetic resonance imaging of the lumbosacral spine showed prolapse of intervertebral disc at the level of lumbar L4-L5. The patient underwent laminectomy and intradural discectomy of L4-L5. Patient had a smooth post-operative recovery with no neurological deficits. A thorough radiological examination can aid in the pre-operative diagnosis of an intradural lumbar disc herniation.

The Prediction of Outcomes in Patients Admitted With Traumatic Brain Injury Using the Rotterdam Score.

OBJECTIVE: The objective was to use the Rotterdam score, which is based on a CT scan, to assess the outcomes of traumatic brain injury patients. MATERIAL AND METHODS: This research, which included 319 head trauma patients, was carried out at the neurosurgery department of a tertiary care hospital between June 2019 and December 2020. The Rotterdam score was calculated for each patient on the basis of the first CT scan after the head injury. The Glasgow Outcome Score was used to assess the results three months following the injury. RESULTS: In our research, there were 270 male patients (84.6%) and 49 female patients (15.4%). The mean age was 37.4 ± 15.4 years and road traffic accidents were observed in 275 people (86.2%). Severe traumatic brain injury (TBI) was seen in 123 patients (38.6%). The most common Rotterdam score was 2 in 86 (27.0%) patients, while it was score 3 in 72 (22.6%), score 4 in 59 (18.5%), score 5 in 41 (12.9%), score 1 in 31 (9.7%) and score 6 in 29 (9.1%). The mortality rate was 33.5% in our patients and good recovery was seen in 150 (47.0%) patients. CONCLUSION: The Rotterdam score is a useful tool to evaluate and predict outcomes in head trauma patients.

Critical Assessment of Various Neurosurgery Training Programs of Pakistan.

AIM: To assess the real challenges faced by neurosurgery residents in developing countries with limited resources and massive workload. MATERIAL AND METHODS: This is a cross-sectional study based on the questionnaire filled by the neurosurgery trainees in Pakistan directed at their training, stress factors, surgical competency, research interest, job satisfaction, and future endeavors. RESULTS: A total of 75 neurosurgery residents participated in study; 73.3% were male. About 61.3% were working for more than 72 hours per week. Average sleeping hours per day were less than 7 hours for 92% of trainees. Only 78.6% were able to receive teaching sessions for at least once a week or more. Practical handling of neurosurgical gadgets like microscope and endoscope was never experienced by 26.7% and 18.7%, respectively. Even the senior most residents were able to perform only 41.08% of their surgeries independently. Financial support was only acceptable to 21.3%, and 60.9% want to leave the country upon training completion. CONCLUSION: The training programs in the developing countries need critical changes to provide favorable learning conditions with availability of appropriate surgical tools, structural changes of training programs, development of research interest, and improvement on the socioeconomic needs of the trainee.

Outcome of diffuse axonal injury in moderate and severe traumatic brain injury.

BACKGROUND: Diffuse axonal injury (DAI) is a common presentation in neurotrauma. Prognosis is variable but can be dependent on the initial presentation of the patient. In our study, we evaluated the outcome of diffuse axonal injury. METHODS: This study was conducted at a tertiary care center from September 2018 to December 2019 and included 133 adult patients with moderate or severe head injury (GCS ≤ 12) diagnosed to have the DAI on the basis of MRI. At 3 months, the result was assessed using the Extended Glasgow Outcome Scale (GOS-E). RESULTS: There were a total of 97 (72.9%) males and 36 (27.1%) females with an average age of 32.4 ± 10 years with a mean GCS of 9 at admission. The most common mode of head trauma was road traffic accidents (RTAs) in 51.9% of patients followed by fall from height in 27.1%. Most patients were admitted with moderate traumatic brain injury (64.7%) and suffered Grade I diffuse axonal injury (41.4%). The average hospital stay was 9 days but majority of patients stayed in hospital for ≤ 11 days. At 3 months, mortality rate was 25.6% and satisfactory outcome observed in 48.1% of patients. The highest mortality was observed in the Grade III DAI. CONCLUSION: We conclude that the severity of the traumatic head injury and the grade of the DAI impact the outcome. Survivors require long-term hospitalization and rehabilitation to improve their chances of recovery.

Outcome of cranial firearm injuries in civilian population based on a novel classification system.

BACKGROUND: Cranial firearm injuries (CFAIs) are expected to be frequent during warfare; however, it is becoming increasingly common among civilian population in our part of the world. These injuries are associated with significant morbidity and mortality in addition to financial loss. The objective of our study is to evaluate the pattern of gunshot injuries to cranium and their outcome. METHODS: The study was conducted on 114 patients presenting with CFAIs to Jinnah Postgraduate Medical Centre, Karachi, Pakistan, between June 2015 and January 2019. Patients were evaluated with respect to age, gender, pattern of injury, Glasgow coma scale on arrival, radiological and clinical assessment, surgical intervention, and Glasgow outcome score measured at 6 months follow-up. RESULTS: Among patients with cranial gunshot, injuries most were males (76.3%). More than 50% patients aged between 18 and 35 years. About 46.5% of patients presented with moderate traumatic brain injury commonly involving the temporal lobe (36.8%). Of total 114 patients, 84.2% were managed conservatively but wound debridement was done in all patients. At 6 months, the overall mortality in our patients was 33.3%. Patients with good outcome (GOS 4 and 5) were 30.7% and 35.9% patients had bad outcome (GOS 2 and 3). Complication rate was 14.9% and the most common complication was disseminated intravascular coagulation in 5.2%. CONCLUSION: Surgical intervention has no significant benefit over conservative management on long-term mortality and should be limited to patients with large intracranial hematomas and intraventricular hematomas causing hydrocephalus.

Gunshot Acquired Spinal Cord Injury in Civilians.

AIM: To understand the differences between operative versus conservative treatment in terms of the outcome measured according to the American Spinal Injury Association (ASIA) impairment scale (AIS) in patients with gunshot acquired spinal cord injuries. MATERIAL AND METHODS: A total of 168 patients were included in this retrospective study. The AIS score was recorded for all survivors who provided consent after emergence from spinal shock. Demographic information and level of injury were also recorded. Patients were categorized according to the management approach, and the outcome was measured at the 6-month follow-up, using the AIS score. Univariate statistics were used for data analysis. RESULTS: Most patients were male (91.6%), with a mean age of 26 ± 4.2 years. A majority of patients (73.2%) had incomplete spinal cord injuries. Among the complete spinal injuries, most involved the thoracic spine (84%). Overall, the thoracic spine was involved in half of the cases (51%). Twenty-six (15.4%) patients underwent surgery. The distribution of AIS score differed between the operative and non-operative groups. In both groups, the AIS score on follow-up differed significantly from admission AIS score (p < 0.001). However, no significant differences were found between groups on the AIS score at follow-up (p > 0.05). CONCLUSION: None of the management approaches showed superior neurological recovery. Therefore, we conclude that outcome improvement in young patients depends on appropriate selection of surgical candidates.