Pakistan Journal Of Neurological Surgery

Correlation Between Cervical Spine MRI Findings and Neurological Deficit in Cervical Spondylosis

Sumaira Noureen — 2026-09-25

Objective: This study aimed to establish the correlation between the findings of cervical spine magnetic resonance imaging (MRI) and neurological deficit in patients suffering from cervical spondylosis.

Materials & Methods: The present study is an observational analytical study that was carried out at Mardan Medical Complex, Mardan, from 23 March 2025 to 23 February 2026. All those who had clinically and radiologically confirmed cervical spondylosis were included, with a total of 242 patients. Neurological examination was carried out using clinical examination, and neurological deficits were divided by levels of severity. MRI was used to assess the cervical spinal cord for evidence of changes in signal intensity, disc degeneration, and spinal canal stenosis. Correlation between imaging findings and neurological status was determined by statistical analysis.

Results: The presentation of most patients was neck pain and radiculopathy. Ninety percent of patients had evidence of disc degeneration on MRI, and a significant number of patients had canal stenosis of varying degrees. Compression of the cord was seen in 42.1 per cent, and changes in signal intensity were noted in 26.4 per cent. There was a great positive correlation between MRI severity and neurological deficit. There were higher grades of neurological impairment in patients with severe stenosis with cord signal changes.

Conclusion: There was a good correlation between MRI changes of the cervical spine and neurologic deficit. MRI in cervical spondylosis was found to be a useful tool to assess disease severity and to predict clinical outcome.

Outcomes and Complications of Endoscopic Endonasal Repair for Spontaneous CSF Rhinorrhea: A Four-Year Experience of 85 Cases

Imran Khan — 2026-09-25

Objective: This study evaluated outcomes of an endoscopic endonasal multilayer repair protocol for spontaneous CSF rhinorrhea at two major tertiary centers in Khyber Pakhtunkhwa, Pakistan.

Materials & Methods: This retrospective descriptive case series included 85 patients with spontaneous CSF rhinorrhea who underwent endoscopic endonasal multilayer repair over four years at two tertiary hospitals in KP, Pakistan. Diagnosis was confirmed by clinical evaluation, CSF analysis, and prone-position contrast MRI, supplemented by CT. Repair was defect-size-based: nasoseptal flap for 1-2 cm/high-flow defects (31.8%), middle turbinate flap for 7-10 mm/moderate-flow defects (35.3%), and fascia lata/fat graft for 3-6 mm/low-flow defects (32.9%). Fibrin glue was used selectively in high-risk cases; lumbar drains were used for high-flow leaks.

Results: Among 85 patients (mean age 39±14.3 years; 68.2% female; mean BMI 28±3.6 kg/m²), the cribriform plate was the commonest site (64.7%). Fibrin glue was used in 64.7%, and lumbar drains in 27.1%. Primary success at 3 months was 97.6% (83/85). Complications included nasal crusting (15.3%) and sinusitis (11.8%), with no meningitis, flap necrosis, or neurological deficit. Two patients (2.4%) required secondary repair, achieving 100% overall success; 2-year success was 95.3%, with late recurrence linked to elevated BMI, high-flow leaks, and radiologic IIH.

Conclusion: This defect-size-based repair protocol achieves excellent primary and overall success rates; long-term surveillance is warranted in IIH or elevated BMI.

Correlation of Reduced Left Ventricular Ejection Fraction with Cognitive Impairment in Heart Failure Patients

Kashif Khan — 2026-09-25

Objectives: To determine the correlation between (Left ventricular ejection fraction (LVEF) and cognitive function among patients with Chronic Heart Failure (CHF) attending the tertiary care cardiology unit.

Materials & Methods: The study was conducted in Mardan Medical College and included 245 patients with chronic heart failure included in the study. The patients were selected one after another during the study period. A complete heart examination was performed on each patient. This included a physical exam, heart tracing test, and heart ultrasound. Left ventricular ejection fraction (LVEF) was the parameter used to measure the pumping power of the heart. A simple questionnaire–the Mini-Mental State Examination (MMSE) was used to assess mental ability.

Results: Patients' mean age was approximately 59 years. Out of 245 patients, 158 were male. The most frequent cause of heart failure was the blockage of the blood vessels that supply the heart. The average pumping ability of the heart was approximately 35%. Patients with weaker heart pumping function also had lower mental ability scores. There was a strong correlation between heart pumping power and mental performance. This indicates that the ability of the brain to function declined as the heart's pumping ability weakened.

Conclusion: Those who had less pumping strength were more likely to have issues with memory, thinking, and understanding. As such, mental functions should be evaluated as a routine part of the evaluation of patients with chronic heart failure.

Outcome in Pediatric Population of Traumatic Brain Injury Based on Rotterdam Score

Nadia Banaras — 2026-09-25

Objective: To evaluate the predictive value of the Rotterdam CT score for in-hospital mortality in pediatric TBI.

Materials & Methods: This prospective observational study was performed in the Emergency Department, Section of Neurosurgery, Trauma Center, Civil Hospital. CT brain imaging was performed at admission, and outcomes were assessed over two weeks.

Results: The patients had a mean age of 10.18 ± 4.74 years; 96 (66.7%) were boys, and 48 (33.3%) were girls. Road traffic accidents were recorded in 64 (44.45%) cases. Nineteen patients died, giving an overall mortality of 13.1%. Mortality rose as the Rotterdam score increased and was greatest at score 6. The association between Rotterdam score and mortality was statistically significant (Chi-square = 15.043; p < 0.001).

Conclusion: In this pediatric cohort, the Rotterdam score was useful for estimating the risk of mortality after TBI.

Diagnostic Accuracy of the Seated Straight Leg Raise Test for MRI-Confirmed Lumbosacral Radiculopathy: A Prospective Study of 500 Patients

Muhammad Shoaib Kibzai — 2026-09-25

Objective: To determine the diagnostic accuracy of the seated straight leg raise (SLR) test in diagnosing lumbosacral radiculopathy with magnetic resonance imaging (MRI) as the standard of reference. Methods: It was a prospective diagnostic accuracy study at a tertiary neurosurgery clinic.

Materials & Methods: The study enrolled 500 adults with a clinical suspicion of lumbosacral radiculopathy. Each patient was subjected to a standardized seated SLR performed by trained clinicians, and results of lumbar MRI were reported by a consultant radiologist. An index test was taken as positive when the typical pain was reproduced in the radicular area below the knee during knee extension or ankle dorsiflexion. MRI showing nerve-root compression and concordant with the level of the symptom was chosen as the reference standard. Diagnostic accuracy values such as sensitivity, specificity, and predictive values were determined.

Results: In 500 patients, 320 (64.0%) were found to have nerve-root compression on MRI. The seated SLR test had a sensitivity of 78.1% (95% CI 73.3%-82.3%), specificity of 69.4% (95% CI 62.4%-75.7%), positive predictive value of 82.0%, and negative predictive value of 64.1% (95% CI 57.2%-70.5%). The total diagnostic accuracy was 75.0%. No adverse events related to the index test were recorded.

Conclusion: The seated SLR is a practical clinical maneuver with good sensitivity and moderate specificity for MRI-confirmed lumbosacral radiculopathy. It serves as a useful screening tool within a comprehensive clinical assessment, helping to rationalize the use of advanced imaging.

Consanguinity and Epilepsy in Khyber Pakhtunkhwa: A Demographic Analysis

Anees Muhammad — 2026-09-25

Objective: The purpose of this study was to assess the relationship between consanguineous parenthood and the prevalence and features of epilepsy in those who have it.

Materials & Methods: A cross-sectional study of 541 epileptic patients was carried out. A standardized form was used to collect data on demographics, parental consanguinity, marital status, clinical features (EEG, MRI, and CT scan results), therapy methods, and geographic location. The chi-square test was used to investigate the link between consanguinity and other risk variables.

Results: Of the 541 participants included in the study, 58.78% (n=318) were male, and 41.22% (n=223) were female. As far as parental consanguinity was concerned, 54.71% (296) said that their parents were cousins, while 45.29% (245) said theirs were not cousins. Consanguinity did not show any statistically significant associations with gender, marital status, abnormal EEG, or availability of diagnostic imaging (p > 0.05 for all). The most often prescribed medication was Epival (43.4%), followed by Tegral (8.85%). Most patients came from Peshawar (18.9%) and the surrounding areas.

Conclusion: Consanguineous marriage was common among families with epileptic patients, but there was no obvious statistical association with specific clinical characteristics. However, the high family clustering of epilepsy and limited access to diagnosis highlight the need for genetic counseling, improved diagnostic instruments, and additional research into inherited risk factors.

Keywords: Epilepsy, parental consanguinity, consanguineous marriages, genetic predisposition to disease, Hereditary disorders, Seizures.

Radial Nerve Palsy Following Humeral Shaft Fractures: A Prospective Evaluation of Management Strategies and Neurological Recovery

Aimal Sattar — 2026-09-25

Objective: Humeral shaft fractures are known to be associated with radial nerve palsy, which is a major clinical issue because of the effects on the functionality of the upper limbs. The research aimed to assess management interventions and test the neurological recovery outcomes of affected patients.

Methods: The study was designed as a prospective observational study to be carried out at Lady Reading Hospital, Peshawar. Two hundred and twenty patients with humeral shaft fractures and radial nerve palsy were selected. Neurological assessment and imaging findings were noted during clinical evaluation. Patients with open fractures, vascular injury, severe fracture displacement, suspected nerve entrapment or transection, or failure to demonstrate neurological recovery during follow-up were selected for surgical management, while the remaining patients received conservative treatment.

Results: Among the 220 patients (mean age 34.5 ± 11.2 years), 140 (64%) were managed conservatively, and 80 (36%) underwent surgical treatment. Complete neurological recovery was achieved in 100/140 (71%) patients in the conservative group and 65/80 (81%) in the surgical group after six months. The mean recovery time was 12.5 ± 4.2 weeks in the conservative group compared with 10.3 ± 3.8 weeks in the surgical group. Early intervention was significantly associated with improved neurological recovery (p = 0.02), and fracture characteristics were also significantly associated with recovery outcomes (p = 0.04).

Conclusion: Radial nerve palsy is a complication of humeral shaft fractures, which can be effectively addressed by a well-chosen method of treatment. Earlier diagnosis and intervention enhance functional outcome and neurological recovery.

Surgical Outcomes of Strip Craniectomy in Metopic Craniosynostosis without Orthotic Helmet Therapy

Jamal Nasir — 2026-09-29

Objective: To evaluate the clinical and cosmetic outcomes of strip craniectomy performed without postoperative orthotic helmet therapy in infants diagnosed with trigonocephaly.

Materials and Methods: A prospective single-centre study was carried out at the Department of Pediatric Neurosurgery, The Children's Hospital Lahore, over a period spanning November 2021 to July 2023. Thirty consecutive patients under four months of age with confirmed metopic craniosynostosis were enrolled. All patients underwent strip craniectomy and were followed for twelve months postoperatively. Operative and outcome data were analyzed using SPSS version 27.

Results: The cohort comprised 30 patients with a mean age of 3.3 ± 0.8 months; 19 were male (63.3%), and 11 were female (36.7%). Mean operative duration was 58.2 ± 5.7 minutes, with an average blood loss of 30 ± 5 mL. Perioperative complications included surgical site infection in two patients and a dural laceration in one, repaired intraoperatively without sequelae. No venous sinus injuries, air embolism, seizures, intracranial hemorrhage, or neurological deficits were recorded. Mean postoperative hospital stay was 3.0 ± 0.5 days. OFC improved from a preoperative mean of 39 ± 1.5 cm to 42 ± 1.4 cm at twelve months.

Conclusion: Strip craniectomy performed without adjunctive helmet therapy is a safe and effective intervention for trigonocephaly in resource-limited environments. Operating between 3 and 6 months of age leverages the plasticity of the neonatal calvaria and rapid cerebral expansion. Future multicenter studies with larger cohorts are needed to validate these findings.

From Cannulation to Relief: Efficacy of H-figure Fluoroscopic Landmark-Guided Radiofrequency in Trigeminal Neuralgia

Nabeel Choudhary — 2026-09-25

Objective: A retrospective case series to evaluate the clinical efficacy, safety profile, and technical feasibility of percutaneous radiofrequency rhizotomy (RFR) using the H-figure fluoroscopic landmark for foramen ovale access in trigeminal neuralgia (TN).

Materials & Methods: This retrospective case series included 37 patients diagnosed with trigeminal neuralgia (TN) who underwent RFR at Sir Ganga Ram Hospital and Jinnah Hospital, Lahore. The foramen ovale was accessed using H-figure fluoroscopic guidance. Sensory and motor stimulation confirmed electrode placement. Pain intensity was recorded using the Barrow Neurological Institute (BNI) pain scale at baseline, postoperative day 1, and 1-month follow-up. Cannulation success, complications, and recurrence were also evaluated.

Results: Of 37 patients, 9 (24.3%) were male and 28 (75.7%) were female, with a mean age of 54.84 ± 12.2 years. Left-sided pain was present in about fifty percent of patients (51.4%). The most affected branch was V2 (48.6%), followed by V3 (24.3%), V2+V3 (18.9%), and V1+V2+V3 (8.1%). Foramen ovale cannulation was successful in 91.9% of cases. Median BNI score improved from 4.0 (IQR 4.0–5.0) preoperatively to 2.0 (IQR 1.0–2.0) on day 1, and 1.0 (IQR 1.0–1.0) at 1 month (p < 0.001). Complications occurred in 6 patients (16.2%), most commonly transient V1 numbness. Four patients (10.8%) experienced recurrence within 18 months.

Conclusion: RFR using the H-figure Fluoroscopic Landmark is an effective technique for trigeminal neuralgia management, providing high rates of pain relief with minimal recurrence and reduced pain intensity in recurrent cases.

Surgical Outcomes of Microvascular Decompression vs. Endoscope-Assisted Microvascular Decompression

Kamran Ullah — 2026-09-25

Objective: To compare the surgical outcomes of conventional microvascular decompression (MVD) and endoscope-assisted microvascular decompression (EA-MVD) in patients with medically refractory primary trigeminal neuralgia (TN), and to evaluate the additional intraoperative value of endoscopic visualization.

Materials & Methods: This retrospective, single-center study involved 35 patients with primary TN who received MVD from July 2024 to December 2025. Twenty patients were treated with conventional MVD, and 15 with EA-MVD. Postoperative pain relief (Barrow Neurological Institute pain intensity score), recurrence, intraoperative findings, operative time, and postoperative complications were the outcomes.

Results: At discharge, overall satisfactory pain relief (BNI I–II) was obtained in 94.3% of patients, and at final follow-up, in 82.9% of patients. There were no significant differences between the two groups for pain relief, recurrence, or complications (p>0.05). Previously unrecognized neurovascular conflicts (33.3%) and incompletion of decompression (20.0%) were identified on EA-MVD and led to further decompression. While the operative time was slightly longer in the EA-MVD group (112.6 minutes vs. 95.4 minutes, p = 0.02), there were no significant differences in complication rates.

Conclusion: EA-MVD provides clinical outcomes comparable to those of conventional MVD while improving intraoperative visualization and identification of occult neurovascular conflicts without increasing complications.

Observations on the Outcome of Lumbar Microdiscectomy

Syed Salman Raza Jaafery — 2026-09-25

Objective: A retrospective observational study of seven cases aimed to find out the outcomes of Lumbar Microdiscectomy as an excellent choice to treat Lumbar Disc Disease causing Neurologic symptoms of pain, numbness, and/or weakness.

Materials & Methods: Cases were included who underwent Lumbar Microdiscectomy at the Department of Neurosurgery, Ali Fatima Hospital/Abu Umara Medical and Dental College, Green International University, Lahore. MRI of the lumbosacral spine was done in all patients. Lumbar Microdiscectomy was done in all cases at the affected level. Post-operatively, all patients were mobilized in bed on the same day, and out-of-bed mobilization was done the next morning after surgery (1^st post-operative day). The results were analyzed using the modified McNab Criteria.

Results: Four (57.1%) patients were male, and 3 (42.9%) were female. The age range was 26 years to 48 years, with a mean age of 40 years. Five (71.4%) patients showed excellent recovery with no post-operative complications. One (14.3%) patient developed post-operative wound infection that was treated with wound debridement and antibiotics and recovered. One (14.3%) patient developed recurrence and was re-operated 5 months after the first surgery. After revision surgery, the patient recovered completely.

Conclusion: Lumbar Microdiscectomy is an excellent procedure for the management of Lumbar Disc Disease resulting in Neurologic symptoms of pain, numbness, and weakness. The outcome depends upon appropriate diagnosis and timely surgical intervention.

Perioperative Use of Diluted Hydrogen Peroxide During Convexity Meningioma Resection: A Retrospective Observational Study

Hanif Ur Rahman — 2026-09-25

Objective: Convexity meningiomas are the most common extra-axial brain tumors and can be challenging to remove due to high vascularity. Hydrogen peroxide has historically been used in neurosurgical procedures because of its oxidizing and hemostatic properties; however, evidence regarding its role in convexity meningioma surgery remains limited. The study aimed to evaluate the feasibility and perioperative outcomes associated with the use of diluted hydrogen peroxide during convexity meningioma surgery.

Materials & Methods: This retrospective study included 86 patients who underwent convexity meningioma surgery at the Ali Institute of Neurosciences from January 2017 to March 2022. Diluted hydrogen peroxide was applied during surgery to alter tumor consistency, control bleeding, and reduce tumor blood supply. Patient demographics, clinical features, and surgical outcomes were analyzed descriptively.

Results: There were 42 males (48.8%) and 44 females (51.2%) with a mean age of 56.3 years. Headache was the most common symptom (72.1%). Gross total resection was achieved in 78 cases (90.7%), with minimal bleeding in most patients. Perioperative complications occurred in 12 cases (13.9%).

Conclusion: The use of perioperative diluted hydrogen peroxide during convexity meningioma surgery appeared feasible and was associated with acceptable surgical outcomes in this retrospective series. However, due to the absence of a control group, definitive conclusions regarding superiority or direct effects on bleeding reduction and tumor resection cannot be established.

Keywords: Convexity meningioma, hydrogen peroxide, outcomes, peri-operative complication, surgical resection.

Burden and Patterns of Traumatic Brain Injury in a Tertiary Care Emergency Department in Punjab, Pakistan: A Retrospective Cohort Study

Eesha Yaqoob — 2026-09-25

Objective: We examined the burden, mechanisms, and clinical outcomes of TBI in a large tertiary care environment in Punjab, Pakistan, to guide national neurotrauma policy.

Materials & Methods: The study’s objective was to explore the epidemiological, clinical presentation, and outcomes of patients presenting with traumatic brain injury at Holy Family Hospital. It was a retrospective cohort study that evaluated 561 patients who presented with TBI to the emergency department of a tertiary teaching hospital from February 2024 to February 2025. Demographic, mechanism of injury, and Glasgow Coma Scale (GCS) data were obtained. Severity was categorized as mild (GCS 13–15), moderate (9–12), or severe (3–8). Chi-square and Fisher’s exact tests were used to measure statistical associations.

Results: The cohort consisted mostly of males (n=448, 79.86 percent) with a mean age of 24.8 ± 21.0 years (range 1–96 years). The age group (2-10 years) was the greatest (n=197, 35.12 percent). The most common cause of injury was road traffic accidents (RTAs) (n=313, 55.79%), and then falls (n=239, 42.60%). The main mechanism in the pediatric population was falls as compared to RTA, which was significantly related to severe TBI (p < 0.001).

Conclusion: TBI in Punjab has a bimodal vulnerability, with young children affected by falls and young adults by RTAs. The large percentage of serious injuries requires the adoption of universal triage mechanisms and the inclusion of TBI as a chronic disease into the national health system.

Radiological Outcome of Bony Fusion After Single-Level Anterior Cervical Discectomy and Fusion Using Iliac Crest Graft vs. Polyetheretherketone Cage in Cervical Spondylosis

Sohaib Ashraf — 2026-09-25

Objective: To compare the surgical outcome of iliac crest graft and polyetheretherketone in anterior cervical discectomy and fusion (ACDF) in cervical spondylosis in terms of radiographic features.

Materials & Methods: It was a randomized controlled trial study in the Neurosurgery Department of Services Hospital, Lahore. Patients were recruited by non-probability, purposive sampling, followed by randomization by the lottery method and divided into two equal groups, i.e. (Group A) Iliac crest graft and (Group B) Polyetheretherketone cage.

Results: In this study, a total of 42 patients were included; 28(66.67%) patients were male, and 14(33.33%) were female, and having mean age ± SD 47.62±6.85 years, with a range of 35- 60 years. In group A, 21 patients underwent an iliac crest autograft, while in group B, 21 patients underwent a polyetheretherketone cage. In the 3^rd post-operative month, 7 patients (33.3%) with an iliac crest bone graft and 8 patients (38.1%) with a Polyetheretherketone cage had trabecular bone formation (p=0.747). In the 6th post-operative month, 6 patients (28.6%) with an iliac crest bone graft and 14 patients (66.7%) with a Polyetheretherketone cage had bridging bone formation (p=0.013). I

Conclusion: ACDF with a PEEK cage has better fusion results than an iliac crest graft in terms of radiographic features. Hence, the PEEK cage can be opted for in ACDF.

Surgical Site Infection After Craniotomy: Incidence, Microbiology, and Modifiable Risk Factors in a Retrospective Cohort of 350 Patients

Muhammad Idrees — 2026-09-25

Background: Post-craniotomy surgical site infection (SSI) is a complication associated with neurological morbidity, repeat operations, and resource consumption. Reported risk factors are leakage of cerebrospinal fluid (CSF), long surgical procedure, drains or foreign objects, and use of antibiotics during the operation.

Objective: To determine the incidence and subtype distribution of 30-day SSI after craniotomy, the microbiology of this condition, and potentially alterable risk factors with special focus on antibiotic prophylaxis and perioperative factors.

Methods: This retrospective cohort study involved 350 adult craniotomy operations between 2022 and 2025. The primary outcome was 30-day SSI, and its subtypes were superficial incisional, deep incisional, or organ/space. Candidate predictors included diabetes, operative time, CSF leak, implants, CSF diversion drains, immunosuppressives or steroids, wound category, and timing and administration of perioperative antibiotic prophylaxis. Multivariable logistic regression estimated adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results: Thirty-day SSI occurred in 25/350 (7.1%) procedures; subtypes were organ/space 10 (40%), superficial 10 (40%), and deep 5 (20%). Cultures were positive in 21/25 (84%). The most common primary organisms were MSSA (5), coagulase-negative staphylococci (5), Cutibacterium acnes (4), culture-negative (4), Streptococcus spp. (3), Enterobacterales (3), and MRSA (1). No perioperative prophylactic antibiotics was associated with increased SSI odds (aOR 7.30; 95% CI 2.18–24.45; p=0.001).

Conclusions: In this cohort, 30-day SSI after craniotomy occurred in ~7%, with organ/space infections comprising 40%. The strongest modifiable association observed was absence of perioperative antibiotic prophylaxis.

Neurosurgical Training with Agentic AI & Robotics

Saman Shahid — 2026-09-25

A Rare Pediatric Case of Twins with 46XY Karyotype, Swyer Syndrome, Associated with Intraventricular Hemorrhage (IVH) and Post-hemorrhagic Hydrocephalus (PHH): A Case Report and Literature Review

Daniel A Encarnacion-Santos — 2026-09-25

Objective: The aim was to identify the underlying causes of phenotypic sex differences and potential difficulties that determine the twins' 46XY chromosomes.

Case Presentation: A 37-year-old woman who delivered twin premature neonates of 29 and 30 weeks of gestation. At the Morozoskaya Children Hospital in Moscow, Russia. She had a history of hereditary thrombophilia (heterozygous Leiden mutation). Microintestinal growth factor (MGF), intrauterine growth factor (IGF), and fetal growth factor (FGF) all showed abnormalities between 24 and 25 weeks. The neurosonography showed male and female twins diagnosed with a confirmed fetal karyotype 46, XY; Swyer syndrome, with Stage 3 intraventricular hemorrhage, obstructive post-hemorrhagic hydrocephalus, and multifocal structural epilepsy with multicystic transformation of the brain hemispheres, movement and tone dysfunction. The management was follow-up with insertion of the extracranial ventricular shunt. After a few weeks, the VP subgaleal shunt was relocated, and the baby was evaluated and monitored by UCI.

Conclusion: In this case, it is a rare condition that was not only accompanied by intraventricular hemorrhage and post-hemorrhagic hemorrhage in the twin prenatally, which were controlled, but the female neonate passed away after all the efforts by the colleagues, while the 46XY male twin survived.