Muhammad Babar Khan

Civilian craniocerebral gunshot injuries in a developing country: presentation, injury characteristics, prognostic indicators, and complications.

BACKGROUND Civilian craniocerebral gunshot injuries (CGIs) are rare but increasing in incidence in the developing world and there is scare literature on presentation, injury characteristics, prognostic indicators, and complications of brain trauma due to projectiles. METHODS A retrospective review of 51 civilian patients with CGI who presented to the Aga Khan University Hospital between 1998 and 2011 was carried out. Presentation, injury characteristics, and complications were analyzed with emphasis on outcomes and prognostic indicators. RESULTS There were 43 male and 8 female patients with an average age of 28.92 (±12.33) years. Twenty-three patients had a Glasgow Coma Scale (GCS) score of 13-15, 6 patients had a GCS score of 9-12, and 22 patients had a GCS score of 3-8 on admission. The overall mortality rate was 22% (n = 11). The most common postoperative neurologic deficits were motor deficits (19 patients) followed by aphasias (11 patients). On univariate analysis, admission GCS score and bi- or multilobar injuries were found to be highly predictive of neurologic outcome. There was no difference in outcomes between penetrating and perforating injuries. We also failed to find a statistically significant correlation between ventricular injury and outcomes in our patients. CONCLUSION Admission GCS and number of lobes involved are highly prognostic of outcome. Patients with a GCS score ≥9 and unilobar injury on computed tomographic scans may benefit the most from surgical management.

Cerebrospinal fluid rhinorrhea: An institutional perspective from Pakistan.

Background: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved over the last two decades. We present here a review of our 11-year data on CSF rhinorrhea and its management at a tertiary care hospital in a developing country, with particular reference to the diagnosis, surgical management and outcome of the disease. Methods: The medical charts of all patients with a diagnosis of CSF rhinorrhea over an 11-year period were reviewed. The etiology of CSF rhinorrhea was classified into three categories: spontaneous, iatrogenic and traumatic. All the patients were divided into three categories based on the type of management as conservative, intracranial and transnasal endoscopic groups. Results: A total of 43 patients fulfilled our inclusion criteria and were included in the final analysis. Eleven of the 43 patients were managed conservatively, while 22 underwent intracranial repairs; 10 patients had transnasal endoscopic repairs. The primary success rate for the transnasal approach was 70% compared to 86% for the intracranial repair. Blood loss, special care unit (SCU) stay and total cost were found to be significantly less in the transnasal endoscopic group. Computed tomography (CT) cisternography was found to have the highest sensitivity and specificity. Further, no postoperative complications were found in the transnasal endoscopic group, while five patients from the intracranial group developed various complications. Conclusions: We conclude that the transnasal endoscopic approach has comparable success rates with the intracranial approach and significantly lower morbidity.

Surgical management of traumatic extra dural hematoma in children: Experiences and analysis from 24 consecutively treated patients in a developing country

Background: Children with epidural hematoma (EDH) present differently than adults. The outcome of treatment is also different. We aim to report our experiences with EDH in pediatric age group in terms of mode of injury, presenting features, management, and outcomes. We also aim to identify different prognostic indicators in pediatric patients with EDH. Methods: We prospectively collected data from 24 consecutively surgically treated pediatric patients. The data collected included presenting features, radiological imaging, details of management, and outcomes. Descriptive analysis was performed and different variables were tested for any statistical significance with Glasgow Outcome Score (GOS). Results: There were 19 male and 5 female patients. The mean Glasgow Coma Scale (GCS) score at presentation was 9.3 ± 4.4. Falls were the most common cause of EDH. Outcome assessment was done at 3 month follow up. A total of 15 patients had a GOS score of 5, 4 patients had a GOS score of 4, 2 patients had a GOS score of 3, while 3 patients had a GOS score of 1. On univariate analysis, admitting GCS score, patients age, the time from injury to admission and injury to surgery, anisocoric pupils at presentation and effacement of basal cisterns were significantly associated with the outcome of GOS score. Conclusion: Falls are the most common mode of injury leading to EDH in children. Lower GCS at presentation, younger age at trauma, increased time since trauma to surgery and admission, anisocoria and effacement of basal cisterns are statistically significant variables in surgically treated pediatric patients of EDH that confer a poorer prognosis. A timely surgical intervention can result in excellent outcomes.

Multiple cerebral hydatid cysts in 8-year-old boy: A case report and literature review of a rare presentation.

Background: Multiple cerebral hydatid cysts are very rare with only a few reports in the literature detailing diagnostic workup, medical management, surgical techniques, possible complications, and outcomes. Case Description: We present the case of an 8-year-old boy who presented with progressively worsening headaches, vomiting, and intermittent fever since 20 days. Diagnostic workup was performed, and magnetic resonance imaging revealed multiple intracranial cysts predominantly in the right frontal region with significant mass effect. A total of 19 intracranial cysts were removed surgically, and the child recovered uneventfully. Conclusions: Neurosurgeons should keep hydatidosis in the list of differentials when evaluating patients with cystic diseases of the brain. Although the removal of such cysts is challenging, outcomes are excellent when cysts are evacuated without rupture and patients show complete resolution of symptoms.

Is surgical spinal decompression for supratentorial GBM symptomatic drop down metastasis warranted? A case report and review of literature.

Background: Symptomatic spinal metastasis from an intracranial primary glioblastoma multiforme (GBM) is very rare. Our literature search identified a total of 42 such patients of which 11 were treated with surgical decompression for spinal metastasis with only one such report from the pediatric age group. Previous studies have reported variable outcomes after surgical management. Case Description: We report the case of a 16-year-old boy who underwent surgical spinal decompression for spinal metastasis after intracranial GBM. The patient regained motor and autonomic function following surgery and reported improvement in pain. We also present findings from a literature review using the PubMed database from 1985 to June 2013 on this subject and compare radiation therapy with surgical decompression as palliative modalities in such patients. Conclusion: There are no evidence-based guidelines available on the subject and no treatment regimen has yet demonstrated survival benefit in these patients. Surgical decompression may be a better option for patients with focal resectable lesions and who are medically stable to tolerate the procedure.

Thoracic and lumbar spinal surgery under local anesthesia for patients with multiple comorbidities: a consecutive case series

Background: Although some patients with symptomatic spinal disease may benefit greatly from surgery, their multiple attendant comorbidities may make general anesthesia risky or contraindicated. However, there is scarce literature describing the efficacy and safety of local anesthesia to perform these operations. Here we report seven patients who successfully underwent spinal surgery utilizing local anesthesia to limit the risks and complications of general anesthesia. Methods: Seven patients for whom general anesthesia was contraindicated were prospectively followed for a minimum of 3 months following spinal surgery performed under local anesthesia. Pain and functional improvement were assessed utilizing the Visual Analog Scores (VAS) and Oswestry Disability Index (ODI) scores. Results: Five patients had interlaminar decompressions for stenosis alone, while two patients had laminectomies for debulking of tumors. The mean duration of surgery was 79.8 ± 16.6 min, the mean estimated blood loss was 157.1 ± 53.4 ml, the mean dose of local anesthetic was 1.9 ± 0.7 mg/kg, and the mean length of hospital stay after surgery was 3.2 ± 1.2 days. There were no intraoperative complications. The surgery resulted in improved VAS and ODI scores consistent with significant improvement in pain (P = 0.017) and functionality (P = 0.011). Conclusions: Performing spinal surgery under local anesthesia is a safe and effective alternative when patients major comorbidities preclude a general anesthetic. For all the seven patients studied, spinal surgery, performed under a local anesthetic, resulted in a statistically significant reduction in pain and improvement in function.

Endoscopic third ventriculostomy for obstructive hydrocephalus: Outcome analysis of 120 consecutively treated patients from a developing country

OBJECTIVES Endoscopic third ventriculostomy (ETV) for the treatment of obstructive hydrocephalus is a relatively new concept amongst neurosurgeons of the developing world. Therefore, this study was conducted to report our experience, patient selection, success rates and complications of ETV and compare our results with the literature from the developed countries. METHODS We performed ETV on 120 patients at our centre and prospectively collected their clinical data on pre designed questionnaires. Success was defined as clinical improvement on 3rd month post operative clinic visit. The data was analyzed using SPSS version 20. RESULTS There were 79 male and 41 female patients. The mean age was 36.1 ± 14.3 years. Overall, ETV was successful in 107 (89.2%) of patients. 4 patients had intra operative bleeding, 4 patients developed CSF leaks while 1 patient had a transient gaze palsy. There was no mortality. CONCLUSION ETV is a very effective treatment modality for treating obstructive hydrocephalus in well selected patients and can be successfully practiced by neurosurgeons in the developing countries.

Enduring improvement in Oswestry Disability Index outcomes following lumbar microscopic interlaminar decompression: An appraisal of prospectively collected patient outcomes

Objectives: Our present study aims to assess the short and long-term postoperative outcome of microscopic interlaminar decompression from a neurosurgical center in a developing country and also aims to further determine any predictors of functional outcome. Materials and Methods: All patients with moderate to severe symptomatic stenosis undergoing elective posterior lumbar spinal decompression were prospectively enrolled in a database. Preoperative, 2 weeks and 2 years postoperative Oswestry Disability Index (ODI) scores were determined for all patients. These scores were retrospectively compared using repeated measures analysis of variance. Further, linear regression modelling was applied to determine the effect of preoperative ODI, body mass index, age, prior physiotherapy, duration of symptoms, and single or multiple level decompression on the change in ODI at 2 weeks and 2 years follow-up respectively. Results: A total of 60 consecutive patients (40 males, 20 females) were included for statistical analysis. The percentage of patients with a minimum clinically important difference (MCID), using an ODI threshold value of 10, was 86.7% (n = 52) at the 2 weeks postoperative follow-up. At the 2 years follow-up assessment, 3.3% (n = 2) patients who had earlier not achieved MCID did so, 78.3% (n = 47) of patients were found to have a change in ODI score of <10 or no change, while 18.3% (n = 11) reported a deterioration in their ODI scores. The preoperative ODI score was an independent predictor of change in ODI score at 2 weeks and 2 years respectively (P < 0.0005). The duration of symptoms prior to surgery was found to predict the change in ODI at 2 years follow-up (P = 0.04). Conclusion: The evidence regarding the long-term and short-term efficacy of microscopic interlaminar decompression in symptomatic lumbar stenosis is overwhelming. Preoperative ODI scores and duration of symptoms prior to surgery can predict postoperative outcomes.