An experience with soft transforaminal lumbar interbody fusion in postoperative discitis not responding to conservative treatment.

OBJECTIVE: To determine the effect of soft Transforaminal Interbody Lumbar Interbody Fusion (sTLIF) in postoperative discitis not responding to conservative treatment. METHODS: This cross-sectional study was conducted in Department of Spine Surgery, CMH Rawalpindi from August 2016 to July 2019. Patients who underwent discectomy were observed and those presenting with postoperative discitis were included in the study. Pain was noted on visual analogue scale before and after the intervention and differences in two readings were noted. Data was collected on predesigned proforma. Statistical analysis was done on SPSS 20.0. RESULTS: Mean age of these patients was 45±12.34 years. The mean pain score on VAS before treatment was 8.33±0.65 and after treatment was 2±0.95. There was statistically significant reduction in pre-treatment and post-treatment pain on VAS (p=0.000). CONCLUSIONS: Postoperative discitis is present among a small number of patients after spine surgery and pain is significantly reduced after the treatment of discitis with TLIF.

Experience of ventriculo-peritoneal shunt insertion in late presenting congenital hydrocephalus.

OBJECTIVE: To evaluate the outcomes of insertion of ventriculo-peritoneal shunts in paediatric neglected hydrocephalus. METHODS: The quasi-experimental study was conducted at the Combined Military Hospital, Rawalpindi, from January 2012 to June 2014, and comprised infants of both genders who presented late with congenital hydrocephalus, having fronto-occipital circumference more than 98 percentile of matched age group. Pre-operative assessment was based upon detailed history, clinical examination, laboratory investigations and computed tomography scan of head. After insertion of ventriculo-peritoneal shunt, patients were followed up for outcomes. Data was analysed using SPSS 17. RESULTS: Of the 30 infants, 12(40%) were girls and 18(60%) were boys. Overall mean age was 7.73±1.41 months (range: 5-10 months). Mean fronto-occipital circumference was 54.30±3.08. Cerebrospinal fluid infection was documented in 12(40%). Abdominal wound complications were observed in 7(23.3%) infants. Ventriculo-peritoneal shunt was removed in 18(60%) and eventually replaced in 18(60%). In-hospital mortality on account of complications was encountered in 13(43.3%). Correlation of fronto-occipital circumference to mortality was significant (p=0.001). CONCLUSIONS: To shunt or not to shunt remains a dilemma for poor-risk infants, but timely reporting of infants with hydrocephalus, proper case selection may improve the outcome of surgical intervention.

Calvarial remodelling surgery: Neurosurgical experience of multidisciplinary craniofacial reconstruction.

OBJECTIVE: To evaluate the safety, cosmetic and functional outcome of craniofacial reconstruction surgery for primary craniosynostosis and clefts. METHODS: This quasi-experimental study was conducted at the Combined Military Hospital, Rawalpindi, Pakistan, from June 2011 to December 2014, and comprised paediatric patients undergoing calvarial reconstructive procedures. Fronto-orbital advancement and reconstruction, total calvarial remodelling and box flap reconstruction techniques were used. Parameters recorded were anomaly, procedure, hospital and intensive care unit stay, theatre time, blood transfusion, dural tears, mortality, wound infection, haematoma/seroma, dehiscence, seizures and cosmetic acceptance. Data was analysed using SPSS 17. RESULTS: Of the 45 patients, 24(53.3%) were boys and 21(46.7%) were girls with an overall mean age of 14.1±21.95 months. Besides, 36(80%) patients were operated for craniosynostosis and 9(20%) for tessier clefts. Surgical techniques of Fronto-orbital advancement and reconstruction, total calvarial remodelling and box flap were used on 18(40%), 18(40%) and 9(20%) patients, respectively. The mean theatre time was 315.33±74.67 minutes (range: 240-390minutes). The mean blood transfusion was 313.34±135.84ml (range: 200-600ml). Major wound infection was seen in 1(2.2%) patient and minor wound infection occurred in 6(13.3%) cases. Post-operative seizures were seen in 1(2.2%). Improved appearance and stable head growth were seen in 41(91.1%) patients. Only 1(2.2%) patient did not survive the procedure. CONCLUSIONS: Early detection of craniosynostosis, neurological assessment, radiological evaluation, differentiating between primary and secondary craniosynostosis and multidisciplinary treatment of craniofacial reconstruction led to optimal treatment.

Early autologous cranioplasty after decompressive hemi-craniectomy for severe traumatic brain injury.

OBJECTIVE: To evaluate the outcome of early replacement of autologous bone flap for decompressive hemicraniectomy in severe traumatic brain injury patients. METHODS: The observational cross-sectional prospective study was conducted at the Neurosurgical Unit of the Combined Military Hospital, Rawalpindi, Pakistan, from July 2011, to June 2014, and comprised patients who underwent cranioplasty after decompressive hemicraniectomy for trauma. Patients over 20 years of age and of either gender were included. Cranioplasty was timed in all these patients using native bone flap preserved in the abdominal wall after decompressive craniectomy. Parameters recorded were mortality, wound infection, subdural collection, wound dehiscence, ventriculomegaly, bone resorption, cosmetic deformity and neurological outcome. SPSS 17 was used for data analysis. RESULTS: Of the 30 patients in the study, 28(93.3%) were males. The overall mean age was age 32.03±8.01 years (range: 20-48 years). Mean cranioplasty time was 66.2±11.50 days (range: 44-89 days). Major infection necessitating bone flap removal was found in 1(3.33%) patient, while minor scalp wound infections, treated with antibiotics and dressings were found in 2(6.66%). Cosmetic18 deformity was seen in 3(10%). Improved neurological outcome was noted in 21(70 %) patients; 6(20%) survived with a moderate to severe disability and 3(10%) remained in a vegetative state. No mortality was found after the procedure. CONCLUSIONS: Early autologous bone replacement for decompressive hemicraniectomy in severe traumatic brain injury patients offered cost-effective, acceptable surgical and improve dneurological outcome.

Financial cost to institutions on patients waiting for gall bladder disease surgery.

BACKGROUND: The aim of this study was to determine the financial costs to institution on patients waiting for gall bladder disease surgery and suggest measures to reduce them. METHODS: This multi-centre prospective descriptive survey was performed on all patients who underwent an elective cholecystectomy by three consultants at secondary care hospitals in Pakistan between Jan 2010 to Jan 2012. Data was collected on demographics, the duration of mean waiting time, specific indications and nature of disease for including the patients in the waiting list, details of emergency re-admissions while awaiting surgery, investigations done, treatment given and expenditures incurred on them during these episodes. RESULTS: A total of 185 patients underwent elective open cholecystectomy. The indications for listing the patients for surgery were biliary colic in 128 patients (69%), acute cholecystitis in 43 patients (23%), obstructive jaundice in 8 patients (4.5%) and acute pancreatitis in 6 patients (3.2%). 146 (78.9%) and 39 (21.1%) of patients were listed as outdoor electives and indoor emergencies respectively. Of the 185 patients, 54 patients (29.2%) were re-admitted. Financial costs in Pakistani rupees per episode of readmission were 23050 per episode in total and total money spent on all readmissions was Rs. 17,05,700/-. CONCLUSION: Financial costs on health care institutions due to readmissions in patients waiting for gall bladder disease surgery are high. Identifying patients at risk for these readmissions and offering them early laparoscopic cholecystectomy is very important.