Salman Sharif

Clinical Outcome in Patients with Early versus Delayed Decompression in Cervical Spine Trauma

Study Design Prospective observational study. Purpose To assess the clinical outcome after early versus late decompression for traumatic cervical cord injury. Overview of Literature Traumatic spinal cord injury is common globally with the most tragic outcomes in the cervical spine. Although recent studies have shown that early decompression results in more favourable outcome, its authority is yet to be established. Methods Study on 98 patients with a traumatic cervical cord injury was conducted over a period of 5 years. The patients who were operated on within 24 hours of the onset of the primary injury (n=34) were classified as the early group, and those who were operated on after 24 hours of the onset of the injury (n=64) were categorized as the late group. The outcome of both the groups was assessed using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at the 6-month follow-up. Results The patients in the early group were operated on at a mean time of 18.4 hours (range, 13-24 hours) while patients were operated on at a mean time of 52.7 hours (range, 31-124 hours) in the late group. At the 6-month follow-up, 7 (23.3%) in the early group and 5 (8.7%) in the late group showed >2 grade improvement in the AIS. Conclusions The results of patients undergoing decompression within 24 hours of the injury are better than those who are operated on later. An attempt should be made to decompress the traumatic cervical spine early in all possible cases.

Traumatic brain injuries: experience from a tertiary care centre in Pakistan.

AIM Traumatic Brain Injury (TBI) is one of the leading causes for morbidity, mortality and economic loss. The impact is much worse in developing countries like Pakistan. The objective of our study was to highlight the etiological pattern and distribution of TBI in Pakistan. MATERIAL AND METHODS From July 2009 to June 2011, 1378 patients presenting to our Accident and Emergency Department with head injury were included in the study. Patients underwent detailed clinical and radiological evaluation as per trauma protocol. RESULTS The most commonly affected age group was 21 to 30 years (34.1%) with male to female ratio of 3.3:1. Injuries were predominantly caused by road traffic accident (62.6%), followed by fall (31.7%) and assault (5.5%). Amongst those with RTA less than 1% of the patients were wearing proper safety equipment. The most common CT scan finding was brain contusion (14.1%); others included traumatic sub-arachnoid hemorrhage (7.1%), subdural hematoma (7.6%), extra-dural hematoma (5.8%) and depressed skull fracture (4.6%). CONCLUSION Motorbike accidents are a major cause of severe traumatic brain injury. Although this can be minimized by wearing proper helmets, its use is limited. Moreover, there is an imperative need to implement proper referral system amongst hospitals citywide in order to minimize the consequences of secondary brain injury.

Intra cranial hydatid cyst: A case report of total cyst extirpation and review of surgical technique.

Hydatid cysts commonly affect liver and lung but it can also affect the brain in rare cases. We report a case of 22 year female with history of headache for one and half years. Intracranial hydatid cyst was diagnosed on computed tomography scan and magnetic resonance imaging. The cyst was delivered without rupture using hydrostatic dissection followed by post-operative anthelminthic medication. Surgery remains to be the standard management. Amongst the surgical techniques described, Dowlings technique is the most acceptable. However, care must be taken in to avoid rupture of the cyst peroperatively which can result in subsequent complications and recurrence. Albendazole and corticosteroids can be used as adjunct to surgical treatment in selective cases.

Smith-Robinson Procedure with an Autologous Iliac Crest for Degenerative Cervical Disc Disease: A 28-Year Follow-Up of 95 Patients

BACKGROUND Long-term clinical results after anterior cervical discectomy and fusion (ACDF) with an autologous iliac crest are rare. The purpose of this study was to assess this, with special focus on pain, functional outcome, and repeat surgery for adjacent segment disease (ASD). METHODS Hospital records of 212 patients who were affected by degenerative cervical disc disease and treated by the Smith-Robinson technique were reviewed. Information about diagnosis, surgery, pre- and postoperative clinical process, and complications was analyzed. Patients were reviewed with a standardized questionnaire including the current neurologic status, Neck Disability Index, EQ-5D, Patient Satisfaction Index, Odom criteria, and limitations in quality of life. RESULTS Ninety-five patients with a mean follow-up of 28 years were evaluated. ACDF was performed at 1 level in 67 and 2 levels in 28 patients. Ninety-two patients reported pain before surgery and 68 patients remained pain free and did not require second surgery. At follow-up, the mean Neck Disability Index was 14%, and mean EQ-5D score was 5. Postoperatively, 96.8% of patients were satisfied and 84.2% of patients reported good to excellent functional recovery. One patient had a hairline fracture at the iliac crest donor site. Fourteen patients underwent second surgery because of degenerative changes, including 11 at the symptomatic ASD. CONCLUSIONS ACDF yields significant decrease in pain, a significant increase in function, and a high degree of patient satisfaction. Overall prevalence for ASD was 12.0% after 25 years. Patients with reoperation had similar clinical outcome regarding pain, compared with patients without reoperation.

Traumatic Spinal Injury: Global Epidemiology and Worldwide Volume

BACKGROUND Traumatic spinal injury (TSI) results from injury to bony, ligamentous, and/or neurologic structures of the spinal column and can cause significant morbidity and mortality. The global burden of TSI is poorly understood, so we performed a systematic review and meta-analysis to estimate the global volume of TSI. METHODS We performed a systematic review through PubMed, Embase, and Cochrane Databases on TSI studies reported from 2000 to 2016. Collected data were used to perform a meta-analysis to estimate the annual incidence of TSI across World Health Organization regions and World Bank income groups using random-effect models. Incorporating global population figures, the annual worldwide volume of TSI was estimated. RESULTS A total of 102 studies were included in the systematic review and 19 studies in the meta-analysis. The overall global incidence of TSI was 10.5 cases per 100,000 persons, resulting in an estimated 768,473 [95% confidence interval, 597,213-939,732] new cases of TSI annually worldwide. The incidence of TSI was higher in low- and middle-income countries (8.72 per 100,000 persons) compared with high-income countries (13.69 per 100,000 persons). Road traffic accidents, followed by falls, were the most common mechanism of TSI worldwide. Overall, 48.8% of patients with TSI required surgery. CONCLUSIONS TSI is a major source of morbidity and mortality throughout the world. Largely preventable mechanisms, including road traffic accidents and falls, are the main causes of TSI globally. Further investigation is needed to delineate local and regional TSI incidences and causes, especially in low- and middle-income countries.

Preservation of hormonal function by identifying pituitary gland at endoscopic surgery

OBJECTIVE The endonasal endoscopic approach has been established for perisellar tumor surgery with a higher resection rate and reduced complications. We analyzed the potential to identify the pituitary gland under endoscopic view, at surgery and see its relation to postoperative hormonal insufficiency in endonasal endoscopic procedures. METHODS Between January 2011 and January 2014, 70 cases of pituitary adenomas with preoperative intact pituitary function underwent endoscopic endonasal transsphenoidal procedures for intrasellar pathologies. Endocrinologists and neurosurgeons followed these patients prospectively. Special attention was paid to intraoperative identification of gland tissue, surgical complications, degree of resection and postoperative hormonal insufficiency. RESULTS The pituitary gland was identified in 57 out of 70 procedures (81.4%). Eleven percent (8 of 70 patients) had persistent pituitary insufficiency. Two of these 8 patients belonged to the group with pituitary gland identification (2 out of 57); thus, when the pituitary gland was identified during the procedure postoperative hormonal insufficiency was seen in 3.5% of cases. Failure of pituitary gland identification presented with hormonal insufficiency of 46.2%. In analysis with Fishers exact test, there was a high significant correlation between the identification of the pituitary gland intraoperatively and normal pituitary function postoperatively (p<0.005). On follow up radical tumor resection was seen in 88% (62 of 70 patients). CONCLUSIONS This study indicates that identification and preservation of pituitary gland tissue and function is possible in endoscopic transsphenoidal surgery. This preservation of gland tissue is a positive predictor of postoperative normal pituitary function.

Superficial Temporal Artery to Middle Cerebral Artery Bypass via a Minimized Approach: Operative Nuances and Problem-Solving Aspects

BACKGROUND The minimized approach for superficial temporal to middle cerebral artery (STA-MCA) bypass surgery is frequently associated with unfamiliar situations and technical problems. OBJECTIVE Description of operative nuances and evaluation of problem-solving aspects to facilitate potential limitations related with a limited exposure approach. METHODS In patients who underwent STA-MCA bypass surgery between February 2012 and August 2014, a preoperative high-resolution computed tomography-angiography 3-dimensional dataset was obtained to select the optimal vessels for anastomosis. Intraoperative exposure was assessed under standard neuronavigation. Anastomoses were performed with specific instruments developed by the authors. Intraoperative video documentation and follow-up records were analyzed retrospectively. RESULTS Seventeen STA-MCA minimally invasive bypass procedures were performed on 12 patients. In all cases, the procedure could be performed through planned craniotomy (mean diameter 2.5 cm). All cases of the procedures dealt with the limitation of surgical field during bypass surgery. The described applications facilitated microsurgical handling in the environment of a limited exposure in all procedures. Follow-up showed all bypasses remained open. CONCLUSIONS The surgical applications, operative techniques, problem-solving aspects, and development of new instruments are described. Potentially, these suggestions may enhance the surgical confidence and convenience to perform STA-MCA bypass surgery with a minimized approach.

The visualization of the surgical field in tubular assisted spine surgery: Is there a difference between HD-endoscopy and microscopy?

OBJECTIVE Expert spinal surgeons criticized endoscopic procedures for poor image quality, in comparison to microscopic visualization. The recent introduction of high definition (HD) digital cameras has shown good results in spinal endoscopy. The aim of this study was to assess endoscopic HD image quality in comparison with microscopic visualization. PATIENTS AND METHODS All posterior lumbar and cervical spinal surgeries of this study were performed with the EasyGO-system in HD resolution. For each comparison, anatomical structures were predefined intraoperatively. A junior resident was randomly required to enter the operating theatre and to identify those structures either using HD-endoscopic or microscopic visualization through the endoscopic working sheath. RESULTS Thirteen lumbar and three cervical procedures were performed. Thirty-four comparisons with a total of 214 predefined anatomical structures were analyzed. The number of predefined structures ranged from 5 to 9 per surgical field. Out of 214 predefined structures, 124 structures (65.8%) were correctly identified under endoscopic view and 88 (41.1%) under microscopic view (p=0.001). Subjective impression of visualization quality were rated 1.25 (very good) for endopscopic images and 1.6 (very good to good) for microscopic view (p=0.02). CONCLUSIONS When using a working trocar and live images, endoscopic HD camera imaging accounted for significantly more reliable identifications of anatomical structures compared to the microscopic view. The subjective impression of video quality is significantly better with HD-optics. The goal of further studies should be to evalute if these findings results in improved surgical outcome.

Preventive gabapentin versus pregabalin to decrease postoperative pain after lumbar microdiscectomy: a randomized controlled trial

Study Design Randomized controlled trial. Purpose The purpose of this study was to compare pregabalin and gabapentin for mean postoperative visual analog score (VAS) for pain in patients undergoing single-level lumbar microdiscectomy for intervertebral disc prolapse at a tertiary care hospital. Overview of Literature Pregabalin has a superior pharmacokinetic profile and analgesic effect at lower doses than gabapentin; however, analgesic efficacy must be established during the perioperative period after lumbar spine surgery. Methods This randomized controlled trial was carried out at our institute from February to October 2011 on 78 patients, with 39 participants in each study group. Patients undergoing lumbar microdiscectomy were randomized to group A (gabapentin) or group B (pregabalin) and started on trial medicines one week before surgery. The VAS for pain was recorded at 24 hours and one week postoperatively. Results Both groups had similar baseline variables, with mean ages of 42 and 39 years in groups A and B, respectively, and a majority of male patients in each group. The mean VAS values for pain at 24 hours for gabapentin vs. pregabalin were comparable (1.97±0.84 vs. 1.6±0.87, respectively; p=0.087) as were the results at one week after surgery (0.27±0.45 vs. 0.3±0.46, respectively; p=0.79). None of the patients required additional analgesia postoperatively. After adjusting for age and sex, the VAS value for group B patients was 0.028 points lower than for group A patients, but this difference was not statistically significant (p=0.817, R2=0.018). Conclusions Pregabalin is equivalent to gabapentin for the relief of postoperative pain at a lower dose in patients undergoing lumbar microdiscectomy. Therefore, other factors, such as dose, frequency, cost, pharmacokinetics, and side effects of these medicines, should be taken into account whenever it is prescribed.

Gunshot Spinal Injury: Factors Determining Treatment and Outcome

OBJECTIVE Spinal gunshot injuries are devastating injuries with significant morbidity and mortality. The purpose of this study was to compare the varied neurologic presentations and radiologic findings with their outcomes after treatment. We applied the Thoracolumbar Injury Classification and Severity Scale and Subaxial Cervical Spine Injury Classification to see whether the management of gunshot patients was performed according to the severity of the scores. METHODS Between 2011 and 2014, 150 consecutive patients with spinal gunshot injury were admitted and treated at Liaquat National Hospital and Medical College, Karachi. We assessed patients neurologically by using the American Spinal Injury Association (ASIA) Scale. The morphologic parameters of injury were measured with the Thoracolumbar Injury Classification and Severity Scale and Subaxial Cervical Spine Injury Classification. The patients were either conservatively or surgically treated, and the ASIA Scale was applied at 1, 12, and 24 months. RESULTS In the study, the ASIA Scale was applied on admission, in which 39% were ASIA A, 9.8% B, 15.6% C, 12.3% D, and 28% E. ASIA A was most commonly seen in the thoracic region. Sixty-two percent of the patients were treated conservatively and 38% surgically. After we applied the thoracolumbar and cervical injury severity scores, 36 patients scored under the nonsurgical criteria, and 79 patients scored in the surgical criteria. Overall improvement was seen in 31% of the patients in whom thoracic region showed greatest progress. CONCLUSIONS Patients with gunshot injury should be considered for surgery when there is potential for improvement, if there is persistent cord compression, or if there is deteriorating or incomplete neurology. Lumbar gunshot injury has a better outcome compared with thoracic followed by cervical injury.