Muhammad Shahzad Shamim

Management of penetrating brain injury.

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.

Neurogenic claudication and radiculopathy as delayed presentations of retained spinal bullet

BACKGROUND CONTEXTnFirearm injuries to the spine may cause injury to the neurological structures and/or to the spine, including ligaments and bones.nnnPURPOSEnPatients usually present with symptoms immediately after injury. However, only a few cases have been reported where a patient is neurologically intact after the initial injury but develops deficits several months or years later. Almost all these cases develop delayed neurological deficit because of bullet migration.nnnSTUDY DESIGNnCase report.nnnMETHODSnA discussion, with a relevant review of the literature, the clinical histories, and radiological findings of two patients who experienced delayed neurological symptoms after gunshot wounds to the spine.nnnRESULTSnOne patient presented after 14 years and the other after 5 months from the day of injury. Both cases are unique in that the delayed symptoms appeared because of formation of a reactive mass around the site of bullet impact. Lack of serial imaging studies is a barrier to the exclusion of bullet migration as an alternate cause of delayed symptoms.nnnCONCLUSIONnThese cases illustrate that retained intraspinal bullets can present with delayed neurological findings secondary to reactive changes around the bullet.

Fuzzy Logic in neurosurgery: predicting poor outcomes after lumbar disk surgery in 501 consecutive patients

BACKGROUNDnDespite a lot of research into patient selection, a significant number of patients fail to benefit from surgery for symptomatic lumbar disk herniation. We have used Fuzzy Logic-based fuzzy inference system (FIS) for identifying patients unlikely to improve after disk surgery and explored FIS as a tool for surgical outcome prediction.nnnMETHODSnData of 501 patients were retrospectively reviewed for 54 independent variables. Sixteen variables were short-listed based on heuristics and were further classified into memberships with degrees of membership within each. A set of 11 rules was formed, and the rule base used individual membership degrees and their values mapped from the membership functions to perform Boolean Logical inference for a particular set of inputs. For each rule, a decision bar was generated that, when combined with the other rules in a similar way, constituted a decision surface. The FIS decisions were then based on calculating the centroid for the resulting decision surfaces and thresholding of actual centroid values. The results of FIS were then compared with eventual postoperative patient outcomes based on clinical follow-ups at 6 months to evaluate FIS as a predictor of poor outcome.nnnRESULTSnFuzzy inference system has a sensitivity of 88% and specificity of 86% in the prediction of patients most likely to have poor outcome after lumbosacral miscrodiskectomy. The test thus has a positive predictive value of 0.36 and a negative predictive value of 0.98.nnnCONCLUSIONnFuzzy inference system is a sensitive method of predicting patients who will fail to improve with surgical intervention.

Safety of untreated autologous cranioplasty after extracorporeal storage at -26 degrees Celsius.

Abstract Background. Given the improved survival of patients requiring decompressive craniectomies, the frequency of subsequent cranioplasties are on the rise. The most feared complication of autologous cranioplasty is infection and one method for reducing the rate of infection, is to store the bone flaps at subnormal temperatures. However, to date there is no defined temperature for flap storage and temperature ranges from − 18 to − 83°C have been described in literature. Considering our limited resources it has been the practice at our center to store bone flaps at − 26°C. In this study, we have retrospectively reviewed our practice and have audited this choice of temperature with respect to the frequency of infections. Methods. A retrospective review was conducted for all cranioplasties performed at our center between January 2001 to March 2011, using autologous bone which was cryopreserved according to institutional protocol. During this period the operative and cryopreservation protocol remained the same. All patient records including charts, notes and laboratory findings were reviewed with a specific focus to identify infections. Results. Of the 88 patients included in the study, only 3 (3.40%) patients were found to show signs of infection. Of these, two patients had superficial surgical site infections which resolved with oral antibiotics (Co-Amoxiclav 1 gm BD for 7 days). However the third patient developed deep surgical site infection requiring re-exploration and washout. All three patients had complete resolution of infection with preservation of autologous bone. Conclusion. Despite our method of keeping the bone flap in freezer at − 26°C we have reported an acceptable rate of infection and raised the notion whether there is a justification for sophisticated and costly equipment for bone flap preservation, especially in resource depleted setups.

Microdiscectomy for Lumbosacral Disc Herniation and Frequency of Failed Disc Surgery

BACKGROUNDnMicrodiscectomy for lumbosacral disc herniations is one of the most commonly performed neurosurgical procedures. The patient demographics, symptomatology, and recovery are highly variable, and surgical outcomes depend on several factors, including patient demographics. Failed disc surgery refers to failure of improvement in patients symptoms following microdiscectomy, and has been observed to occur in up to 12% of patients. To date, no study form Pakistan has looked into patient demographics and failed disc surgery rates within the local context.nnnOBJECTIVEnThe aim of this study was to review the demographics of the patient population presenting for surgical treatment of lumbosacral disc herniations and to review our results of lumbosacral microdiscectomy at a university hospital in Pakistan.nnnMETHODSnThis is a retrospective analysis of all adult patients admitted from January 2003 to January 2008 for symptomatic lumbosacral disc herniation requiring microdiscectomy, at the Aga Khan University Hospital, Karachi. Data were collected through our medical records, on a standardized form. Basic information about the patient population, disease process, modes of nonsurgical treatment, and details on surgery and postoperative course were recorded and analyzed using SPSS.nnnRESULTSnFive hundred one patients were studied, based on inclusion criteria. The mean age was 41.2 years; 347 (69%) patients were male and 154 (31%) female. Mean body mass index of the population was 26 and was higher in females. All patients primarily presented with radiculopathy, and the mean duration of these symptoms was 438 days. Mean duration of nonoperative management was 53 weeks. Fifty-one patients (10.2%) had previously undergone spine surgery. A total of 442 (88%) patients were operated at single disc level, and the rest at two levels. Sixty-six (13%) patients were operated for upper lumbar disc herniations. Mean operative time was 94 minutes, and the most common complication was dural tear. Mean length of hospital stay was 5 days (2-12 days). Mean follow-up was 48.3 weeks (4 weeks to 14 years). Complete resolution of symptoms was seen in 360 (71.9%) patients and failed disc surgery was diagnosed in 42 (8.4%) patients. Twenty-six patients (5.2%) were reoperated upon, with gradual improvement. The authors report an overall failed back surgery rate of 8.38%.nnnCONCLUSIONSnOverall our results were comparable to published international literature. However, the authors observed significant differences in demographics, especially in terms of age, gender distribution, and mean BMI of patient population as well as frequency of involvement of upper lumbar discs.

Recurrent atypical meningioma seeding to surgical scar.

thickened arachnoid. Cord was anteriorly adherent at D4 level. There was kinking and lateral rotation of the cord. Cord herniation through the small dural defect was identiÞ ed and reduction was done by microsurgery and the defect was closed with teß on graft. Patient had good recovery and was able to ambulate with support. Postoperative MRI revealed good reduction of the herniation and restoration of normal anatomy [Figure 2].

Injuries due to fall make summer time power outages a potential public health issue

Falls are a significant cause of morbidity and mortality, especially in children and in under-developed countries. Unexpected power outages in Karachi have become a frequent problem. This study was carried out at Jinnah Postgraduate Medical Centre, Karachi, to explore an association between increasing power outages and frequency of falls. Data for all injuries were collected prospectively, and the year 2006 was chosen for analysis at it had worst power outages. Injuries were classified as those occurring in summer (April to July) or winter (December to March) and were compared between the two seasons. Total injuries in study duration was 2599, mean age was 21 ± 18 years (male:female 3.2:1) and 43% of victims were children. Injuries in two seasons were comparable (summer 1266, winter 1333) but injuries due to fall were more in summer (574 versus 470, OR= 1.5; 95% CI = 1.3, 1.8), especially in children (P = 0.001). Frequency of falls were much more in 2006 as compared with either 2005 (OR = 1.59; 95% CI = 1.37, 1.83) or 2004 (OR = 1.22; 95% CI = 1.05, 1.42). Karachis hot and humid climate and frequent power outages encourages families to spend time on rooftops or balconies, or to leave the windows open. Understandably, we found a higher frequency of falls, especially of children in all summer months, observations shown by others as well. However, to the best of our knowledge, this is the first study which points toward a possible association between increasing power outages and falls, especially involving children, implying power outages as a potential health hazard. On a similar note but in an area with cold climate, investigators have previously found an association between power outages and heater related injuries. Larger, more in depth, prospective studies are recommended to validate our findings. Language: en

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

Abstract 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)u2009=u20091–3]. 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: 31.4u2009±u200918.7 years) were included in the study. Mean Glasgow coma score at presentation was 8.1u2009±u20093.6. RCTS was negatively correlated with GOS (ru2009=u2009−0.370; pu2009<u20090.001). The area under the curve was 0.687 (95% CI: 0.595–0.779; pu2009<u20090.001) and 0.666 (95% CI: 0.589–0.742; pu2009<u20090.001) for mortality and unfavourable outcomes, respectively. RCTS independently predicted both mortality (adjusted odds ratio for RCTSu2009>3 compared with RCTSu2009≤3: 2.792, 95% CI: 1.235–6.311) and other unfavourable outcomes (adjusted odds ratio for RCTSu2009>3 compared with RCTSu2009≤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.

Predictors of poor outcome of decompressive craniectomy in pediatric patients with severe traumatic brain injury: a retrospective single center study from Pakistan

ObjectiveThis study aimed to determine the risk factors associated with poor outcome of decompressive craniectomy (DC) for severe traumatic brain injury (TBI) in pediatric patients.MethodsThis retrospective study is conducted on pediatric population (age 1–15xa0years) presenting with TBI who underwent DC at our institute between January 2000 and 2010. Based on Glasgow outcome score (GOS) at a minimum follow-up of 5xa0months, patients were divided into two groups, namely poor outcome (GOS 1, 2, and 3) and good outcome (GOS 4 and 5). Records were reviewed and analyzed for preoperative and intraoperative predictors.ResultsWe found 25 patients who were eligible as per selection criteria. Mean age at presentation was 6u2009±u20094xa0years and there was male preponderance (84xa0%). Fall (60xa0%) was the most common mechanism of injury followed by gunshots and road traffic accident. On univariate analysis, presenting GCS ≤5 (p valueu2009=u20090.009), delay in presentation of more than 150xa0min (p valueu2009=u20090.010), DC performed after more than 4xa0h of arrival in hospital (p valueu2009=u20090.042), and intraoperative blood loss exceeding 300xa0ml (p valueu2009=u20090.001) were significant predictors of poor outcome.ConclusionOur study suggests that DC in children is not only a life-saving procedure, but also leads to a good functional outcome after severe injury. However, patient selection still remains an important aspect, and the above-mentioned factors should be considered while deciding for DC to improve survival. Further prospective studies on larger sample size are warranted to validate our results.

Surgical grand rounds at a University Hospital. Applying "publication presentation index" to evaluate outcomes.

BACKGROUND AND OBJECTIVEnSurgical grand rounds (SGR) are an important educational activity in all teaching hospitals however each institute has its own way of conducting them. At our institute, grand rounds in the Department of Surgery include an original research presentation by residents. The publication of the research work acts as a measure of its success. In this study we analyzed the outcome of this activity and review factors affecting their progression to publication.nnnMETHODOLOGYnWe conducted a retrospective review of a prospectively maintained database of all presentations made at the Surgical Grand Round at a University Hospital from January 2001 to December 2010. Presentations with incomplete follow up records were excluded from analysis. A Publication-Presentation Index (PPI) was used to evaluate outcomes of SGRs and to study factors influencing outcomes. Differences in PPI in each category were calculated using the chi square test.nnnRESULTSnTotal of 470 presentations were made. Majority presented retrospective studies (73%). Majority of the presentations were made by junior residents (year 1-3, 62%). Following presentation, 279 (59.4%) studies were presented at a national conference, 80 (17%) were presented at an international forum while only 99 (21.1%) studies were published. Mean presentation to publication time was 34.8 months. Study design, level of resident, section of surgery, sample size and national/international presentation were associated with conversion to a publication (all p < 0.05). Overall PPI was 0.32. Randomized controlled trials had the highest PPI (0.67).nnnCONCLUSIONnThe proportion of SGR presentations converted into national/international presentations and/or publications was found to be low. The PPI has a potential to be used as a tool to study the association of presentation to publication.