To Determine the Surgical Outcome of Anterior Cervical Corpectomy and Fusion without Fixation for Ossification of Posterior Longitudinal Ligament.

AIMS: The purpose of our study is to evaluate the surgical outcome in patients undergoing anterior cervical corpectomy without fixation with plates and screws for the treatment of ossification of posterior longitudinal ligament (OPLL). SUBJECTS AND METHODS: The type of study was case series and was conducted from January 2015 to December 2015 for 1-year duration at the Department of Neurosurgery at a Tertiary Care hospital in Karachi, Pakistan. A total of n = 20 patients (16 men and 4 women; mean age of 57.45 ± 6.4 years [range: 45-68 years]) were included after thorough clinical history and physical examination. Neurological evaluation was done using the Japanese Orthopedic Association (JOA) scoring system. The pre- and post-operative JOA scores were used to calculate recovery rate (RR) of the patients. Radiographic assessment was done using various modalities such as X-ray, computed tomography scan, and magnetic resonance imaging. Surgical outcome and complications were studied and the data were analyzed using SPSS 21. RESULTS: After the uniform follow-up period of 12 months, mean JOA scores improved from 9.1 ± 1.37 preoperatively to 14.3 ± 1.69 postoperatively and mean RR was 67.01 ± 15.5%. All the patients showed successful osseous fusion while one patient did not. Two patients developed cerebrospinal fluid leakage, one patient developed recurrent laryngeal nerve palsy, and one expired due to iatrogenic neurological deterioration. CONCLUSION: Anterior cervical corpectomy without fixation with plates and screws is an effective surgical procedure for the treatment of OPLL (for up to three cervical levels of OPLL). It gives good neurological recovery with fewer postoperative complications.

Comparison of Phenytoin versus Levetiracetam in Early Seizure Prophylaxis after Traumatic Brain Injury, at a Tertiary Care Hospital in Karachi, Pakistan.

AIMS: The aim of the study was to compare the efficacy of phenytoin and levetiracetam for seizure prophylaxis in patients with severe traumatic brain injury (TBI). SUBJECTS AND METHODS: A randomized controlled trial was conducted over a period of 6 months, at a tertiary health care center in Karachi, Pakistan. Patients with TBI were divided into two groups. Patients in Group A were given phenytoin, whereas Group B patients received levetiracetam. The first dose of the drugs was given within 24 h of injury and continued for 7 days. Data were collected using a predesigned pro forma. All the patients who were in a state of persistent coma, had altered mental status, or had clinical signs of seizures underwent a 1-h electroencephalographic (EEG) recording to observe the seizures, the first EEG was done on the 1st day posttrauma and a second one was done on day 7 of drug use, both the EEGs were compared for changes. We also analyzed the patients according to their duration of antiepileptic drug therapy, length of hospital stay, and complications during therapy. RESULTS: One hundred and forty (117 males and 23 females) patients who presented with TBI having a mean age of 29.48 ± 16.24 years were part of the study. The most prevalent cause of brain injury was road traffic accidents in 72.85% patients. There was no significant relationship between the antiepileptic drug used with the initial EEG (P = 0.313) and seizure activity (P = 0.502). However, a significant correlation of the antiepileptic drug used was found with EEG (P = 0.002) and seizure activity (P = 0.014) on follow-up. Patients who took levetiracetam had decreased the incidence of abnormal EEG and seizure activity on follow-up. There was not any correlation between GCS both initially (P = 0.845) and on follow-up (P = 0.104) with the antiepileptic drug used. CONCLUSION: The incidence of abnormal EEGs and seizure activity in patients with TBI is the same for both levetiracetam and phenytoin for the initial 7 days post-TBI; however, the incidence of seizures is lower for patients who used levetiracetam on the subsequent follow-up.

Levetiracetam Induced Increase in Creatine Phosphokinase Levels.

Levetiracetam is an antiepileptic drug used for the treatment of generalised or partial seizures, either alone or in a combination therapy. Adverse effects have been reported with its clinical use, including headache, dizziness, liver failure etc. A rare but an important adverse effect is an increase in creatine phosphokinase (CPK) levels with its use. Herein, we present a case of 43-year male, known intravenous (IV) drug abuser with a history of decompressive craniotomy. Patient presented with severe behavioural disorder for which risperidone was given. Five days later, he started having high grade fever, hyperventilation and uncontrolled generalised tonic-clonic seizures (GTCS). After initial management of seizures, levetiracetam was started in combination with topiramate for seizure control. Seizures remained subsided but CPK levels, which were normal at the start of therapy, began to rise and reached tremendous levels of 29,000 mg/dl within a span of a week. Levetiracetam, suspected as a cause of this increase CPK levels, was stopped immediately and the levels returned to baseline within one week. This report provided us with an important step in the management of seizures with levetiracetam.

Frequency of infection associated with ventriculo-peritoneal shunt placement.

OBJECTIVE: To compare the frequency of infection in protocol-based and random ventriculo-peritoneal shunt placement in patients with hydrocephalus. METHODS: The prospective, observational study was conducted at Civil Hospital, Karachi, from October 2014 to March 2015, and comprised patients having ventriculo-peritoneal shunt placement who were randomly categorised into Group A that had protocol-based procedure and Group B that had random shunt placement. All patients were followed up for six months to record final outcomes after surgery. A pre-tested questionnaire was used to document findings. SPSS 16 was used for data analysis. RESULTS: Of the 210 patients, there were 105(50%) each in the two groups, overall having 117(55.7%) boys and 93(44.3%) girls. The frequency of infection was 8(7.6%) in Group A and 19(18.1%) in Group B (p<0.05). CONCLUSIONS: With a meticulous surgical technique and modifications to the pre-, intra-, and postoperative care, it is possible to significantly reduce the incidence of shunt infection.

Cervical chordoma involving C3/C4: A case report.

Chordoma is a rare, indolent but locally invasive, osteolytic, slow growing, low grade, primary bone malignancy, derived from the embryonic remnants of the notochord. It is a midline tumour and it predominantly emerges from the axial skeleton. The most commonly observed location of a chordoma is in the sacrococcygeal region ( 50 to 55% ) followed by the cranio occipital region ( 25 to 30% )We present a case of a 30 years old lady who came to us with complaints of difficulty in walking and inability to hold objects in both hands. MRI showed collapse of C3 and C4 vertebral bodies with a large mass extending into paravertebral tissues and causing spinal cord compression. A preamble diagnosis of a chordoma at level of C3-C4 spine was made, a biopsy done to confirm the diagnosis of a chordoma and surgical excision was carried out. No recurrences or metastasis were noted in a follow up at 6 month post operatively.

Superficial Temporal Artery Pseudoaneurysm: A Case Report.

Pseudoaneurysms of the superficial temporal artery are an uncommon vascular lesion of the external carotid system and most often the result of blunt head trauma. The frequency of pseudoaneurysms of the superficial temporal artery developing after craniotomy is exceedingly low and only a few cases have been reported. We present a case of pseudoaneurysm of this type in a 45-year-old male who underwent craniotomy for excision of meningioma. One month postoperatively, the craniotomy flap exhibited an enormous diffuse pulsate swelling. The suspected diagnosis of pseudoaneurysm arising from superficial temporal artery was confirmed on angiography. Surgical excision was done and no recurrences of the tumor or aneurysm were noted on subsequent follow up.

FREQUENCY OF POST-OPERATIVE FAECAL INCONTINENCE IN PATIENTS WITH CLOSED AND OPEN INTERNAL ANAL SPHINCTEROTOMY.

BACKGROUND: Fissure in ano is one of the commonest benign and painful proctologic diseases causing considerable morbidity and reduction in quality of life. There are medical as well as surgical treatment options for anal fissure. The study was conducted to compare the frequency of postoperative faecal incontinence in patients with closed lateral internal anal sphincterotomy with von-greaves knife versus standard Park's operation (open method) for chronic anal fissure. METHODS: This was a randomized controlled trial (RCT) was conducted at the Department of Surgery, KVSS, S.I.T.E. Hospital, Karachi, for a period of six months from 13th February to 12th August 2011. Ninety four consecutive patients having chronic anal fissure were assigned through blocked randomization to groups A & B, with 47 patients in each group. Closed lateral internal anal sphincterotomy (CLIAS) via von-greaves knife was carried out in patients of group-A whereas patients of group-B were subjected to open internal anal sphincterotomy (OIAS) also known as Parks' procedure. Faecal incontinence was noted on the 5th post-operative day. Data was analysed using SPSS 16. RESULTS: There were 81 (86.2%) males and 13 (13.8%) females with male to female ratio being 6:1. Mean age was 38.38 mp ± 14.56 years. Post-operative faecal incontinence in patients undergoing CLIAS was 4.3% while it was 21.3% in those undergoing OIAS with a p-value of 0.027. CLIAS with von-greaves knife is effective in reducing faecal incontinence on 5th postoperative day as compared to standard OIAS. CONCLUSION: CLIAS with von-greaves knife is effective in reducing faecal incontinence on 5th postoperative day as compared to OIAS (Park's procedure). Therefore, this technique may be used in future regularly to treat chronic anal fissure for prevention of this morbidity.

Chronic non puerperal uterine inversion secondary to sub-mucosal fibroid.

Inversion of uterus is a rare clinical condition, if not associated with puerperium or third stage of labour. Non-puerperal uterine inversion usually results secondary to tumour implanted at fundus of the uterus. An unusual case of non-puerperal uterine inversion caused by a large submucosal fundal fibroid is reported where a 39-year-old woman presented with heavy bleeding per vaginum and profuse vaginal discharge. Uterine inversion was corrected abdominally by Haultain's procedure after vaginal myomectomy followed by abdominal hysterectomy. Both the ovaries were conserved.