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Background: As part of the ‘small round-cell tumor’ family, Ewing’s sarcoma (ES) is a malignant mesenchymal tumor classified as a primitive neuroectodermal tumor (PNET). Within the PNETs, spinal extraosseous extradural lesions are exceedingly rare. Case Description: A 19-year-old male presented with a one-month history of back pain and paraparesis with loss of urinary control. The MRI revealed an intradural, extramedullary mass at the T3-T4 level. Intraoperatively, the tumor was solely extradural, without evidence of local invasion; it was entirely removed. Due to the high risk of metastasis, the patient was subsequently treated with chemotherapy and radiation. In addition, similar studies on PNETs were reviewed. Conclusion: A 19-year-old male presented with a paraparesis attributed to an extraosseous extradural ES at the T3-T4 level. Following total gross resection, he was successfully managed with chemotherapy and radiation. The patient has been in remission for one month.

Background: Polymethyl methacrylate (PMMA) cranioplasty, while widely prevalent, has limitations associated with freehand manual intraoperative molding. PMMA has been superseded by titanium or Polyetheretherketone implants, prefabricated commercially from preoperative CT scans, and boasting superior clinical and cosmetic outcomes. However, such services are extremely inaccessible and unaffordable in the lower-middle-income country (LMIC) settings. The study aims to describe, in detail, the process of making ultra-low-cost patient-specific PMMA cranioplasty implants with minimum resources using open-access software. We report the first such service from the public health-care system within Pakistan, a LMIC. Methods: Using open-source software, preoperative CT heads were used to prefabricate three-dimensional implants. Both implant and cranial defects were printed using polylactic acid (PLA) to assess the implant’s size and fit preoperatively. From the PLA implant, we fashioned a silicon mold that shapes the PMMA implant. Ten patients who underwent cranioplasty using our technique for various cranial defects with at least a 12-month follow-up were retrospectively reviewed. Clinical, cosmetic, and radiological outcomes were objectively assessed. Results: Etiology of injury was trauma (8), malignant MCA infarct (1), and arteriovenous fistula (1). We produced seven frontotemporal-parietal implants, one bifrontal, one frontal, and one frontoparietal. At 1 year, eight patients reported their cosmetic appearance comparable to before the defect. Radiological outcome was classified as “excellent” for eight patients. No postoperative complications were encountered, nor did any implant have to be removed. One patient’s implant involving the orbital ridge had an unsatisfactory cosmetic outcome and required revision surgery. The average cost per implant to the National Health Service was US$40. Conclusion: Prefabricated patient-specific PMMA cranioplasty implants are cost-effective. A single surgeon can fashion them in a limited resource setting and provide personalized medicine with excellent clinical/cosmetic-radiological results. Our method produces patient-specific cranioplasty implants in an otherwise unaffordable LMIC setting.

Objective:  To evaluate the prognostic factors affecting functional clinical outcomes in severe traumatic brain injury patients with traumatic mass lesions undergoing decompressive hemicraniectomy (DHC). Materials and Methods:  A prospective cohort of 85 patients of severe traumatic brain injury patients with traumatic mass lesions underwent a unilateral decompressive hemicraniectomy. Functional outcomes were assessed using the Glasgow Outcome Score at 28 days, 3 months, and 6 months. Bivariate analysis (chi-squared) was used to identify parameters that resulted in poor outcomes and multiple regression was used to identify independent factors predicting poor outcomes. Results:  85 patients were recruited. Functional outcomes were dichotomised as favourable (Glasgow Outcome Score of 4 – 5) and poor (Glasgow Outcome Score 1-3) and evaluated at 28 days, 3 and 6 months. A total of 59 patients expired (69.4%). Bivariate analysis revealed GCS 3 – 5 at presentation (P = 0.002), midline shift greater than 7.5mm (P < 0.001), the volume of the mass lesion more than 40ml (P = 0.006) resulted in a poor outcome. Age dichotomised to less than or more than 50 years bordered statistical significance (P = 0.063). Only GCS at presentation and midline shift were independent factors that predicted poor outcomes when controlling for covariates.  Conclusion:  Decompressive hemicraniectomy can be a lifesaving intervention in managing severe traumatic brain injury patients with traumatic mass lesions. However, its use needs to be employed judiciously.

Background and Objective In lower-middle-income countries such as Pakistan, public hospitals provide free healthcare but suffer from poor management and misgovernance, negatively impacting service provision. One aspect of this is operating theater time (OTT) utilization. In a 1,600-bed hospital with a 22 million catchment population, we noticed significant delays and inadequate OTT efficiency at the neurosurgery department of Jinnah Hospital, Lahore, Punjab, Pakistan. This audit aimed to analyze the neurosurgical OTT utilization, identify delays, and highlight managerial deficiencies and areas for improvement while comparing our workflow with contemporary international literature. Materials and Methods We prospectively audited OTT utilization at the neurosurgical department. All elective surgeries from January to April 2021 were included to identify delays concerning patient transfer, anesthesia team arrival, preparation and intubation time, operative time, and anesthesia extubation time. Results Fifty-six per cent of OTT was utilized operating. Sources of delay included the delayed arrival of anesthesia team (4.7%) and the delay in transferring patients to OT (9.7%). Anesthesia intubation and preparation time accounted for 23% of OT utilization and was significantly longer than the comparable international studies. Extubation time accounted for 5.7% of OT utilization. The issues surrounding transfer delays and prolonged anesthesia time were discussed, with strategies to address them developed with close vital input from our anesthesia colleagues and ward staff. Conclusion Gross delays relatively simple in nature were identified due to poor management and less than ideal interspecialty coordination. Most delays were avoidable and can be addressed by proper planning, optimization of patient transfer and resources, and, most importantly, improved communication between surgeons, anesthetists, and ward staff. This can ensure optimal use of theater time and benefit all specialties, including ancillary staff, and, most importantly, the patient. A reaudit is warranted to assess the impact of interventions on OTT utilization.

Objective:  To present our early experience with percutaneous transpedicular screw fixation for thoracolumbar fractures at a tertiary care hospital in Pakistan. Material & Methods:  A case series of 20 patients with thoracolumbar fractures, who met the inclusion and exclusion criteria were followed for up to six months to evaluate their functional status using the Oswestry Disability Index (ODI). Kendall’s tau, Spearman’s rho and Pearson correlations were conducted to draw useful conclusions. Results:  85% patients’ injury was reported from ‘fall from height’. 55% of the fracture was the dorsal-lumbar junction (T12-L1). Burst type morphology was reported in maximum number of patients (65%). 55% of patients were reported to be neurologically intact. ODI score’s mean percentage decreased from 40% to 23% during the first week to six months, indicates an improvement in the disabilities. A significant (p<0.050) positive correlation was found between fracture morphology and ODI. All patients had an accurate screw trajectory postoperatively and no postoperative complications were documented. Neurology was stable for all patients at 1, 3 and 6 months. Conclusion:  Percutaneous transpedicular screw fixation can be a viable approach for thoracolumbar burst fractures with intact posterior ligamentous complex in all types of thoracolumbar fractures, including type C and leads to an improvement the quality of life. Fracture morphology has a significantly positive correlation with a higher disability index score, with more severe fracture morphologies as per the Thoracolumbar Injury Classification and Severity (TLICS) score having a higher disability.

Background: Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view. Methods: A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital’s pediatrics’ anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented. Results: The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic. Conclusion: Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting.

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