Salaar Ahmed

Background: Traumatic spinal cord injury (SCI) is a major cause of long-term disability worldwide. While early surgical decompression is increasingly recommended to optimize neurological recovery, timely intervention remains challenging in many low- and middle-income countries (LMICs) due to delayed referrals, limited specialist availability, and resource constraints. This study evaluated neurological outcomes following delayed surgical management of traumatic SCI in a resource-limited setting and identified factors associated with recovery. Methods: This retrospective cohort study included 68 patients with traumatic SCI who underwent surgical intervention at Ayub Teaching Hospital, Abbottabad, Pakistan, between January 2019 and February 2022. Due to healthcare system constraints, all patients underwent surgery more than 10 days after injury. Patients with fractures below L2, those who died within 12–18 months of surgery, and those with incomplete records were excluded. Neurological recovery was assessed by change in Frankel grade between preoperative assessment and final follow-up. Associations with clinical variables were analyzed using Chi-square and Fisher’s exact tests. Results: The cohort comprised 39 males and 29 females with a mean age of 35 years. Lumbar fractures were the most common injury pattern, and instrumentation combined with decompression was the most frequently performed procedure. Despite delayed intervention, neurological improvement was observed in 72.1% of patients, with no patient experiencing deterioration. Preoperative Frankel grade was strongly associated with postoperative recovery ( p < 0.001), and fracture level was also significant ( p = 0.042), with lumbar injuries showing the most favorable outcomes. Age, sex, fracture multiplicity, and surgical technique were not significantly associated with improvement. Conclusion: Meaningful neurological recovery remains achievable following delayed surgical management of traumatic SCI in resource-constrained settings. Preoperative neurological status and fracture level were the strongest predictors of recovery. These findings provide important outcome data from an LMIC setting and may assist clinicians in counseling patients when early intervention is not feasible.

Interpreting pain improvements after interventions in clinical settings is challenging because placebo effects can influence patient-reported outcomes. In clinical practice, pain intensity reductions of 30% or greater are commonly considered indicative of meaningful analgesic benefit. However, the likelihood of achieving such reductions after placebo interventions is not known. We conducted a comprehensive meta-analysis to quantify pain intensity changes reported after placebo interventions in clinical trials of facial pain (FP). We systematically searched for randomized controlled trials (RCTs) and uncontrolled case series of FP treatments that included placebo or sham arms. The primary outcome was percentage change in pain intensity. The primary analysis focused on RCTs, with pooled effect sizes estimated using random-effects meta-analysis. Data from 115 studies (n = 3,208) were analyzed, including 71 RCTs (n = 2,128) and 44 uncontrolled case series (n = 1,080). Sham interventions yielded an average pain reduction of 29.73% (95% CI 24.09%-35.36%), with a prediction interval (−14.51% to 73.96%) among RCTs. Placebo responses varied by diagnosis ( P < 0.001), with larger effects in temporomandibular disorders and classical trigeminal neuralgia. Cumulative probability analyses showed that ≥50% pain relief occurred in ∼25% of placebo-treated patients, whereas ≥75% improvement was reported in ∼2.5%. In FP, placebo interventions often produce mild to moderate relief but rarely yield dramatic improvements of ≥75%. These results can guide the interpretation of reported pain relief in clinical settings and inform clinical trial design in chronic pain conditions, suggesting that ≥75% pain intensity reductions after analgesic interventions are unlikely to be primarily driven by placebo effects.

BACKGROUND: Middle meningeal artery (MMA) embolization has emerged as an effective adjunctive treatment for chronic subdural hematomas (SDHs) and is generally associated with a favorable safety profile. As utilization increases following recent randomized trials, uncommon complications are increasingly being recognized. The authors present a case of bilateral subdural empyema following bilateral MMA embolization. OBSERVATIONS: A 67-year-old man underwent bilateral MMA embolization for acute-on-chronic SDHs. Three weeks after an initially uncomplicated procedure, he developed progressive confusion, dysarthria, facial weakness, and hemiparesis. Serial CT and MRI demonstrated stable bilateral subdural collections without definitive radiographic evidence of empyema. Surgical evacuation was pursued because of persistent neurological deficits despite correction of alternative metabolic abnormalities. Intraoperatively, purulent material was encountered in both epidural and subdural spaces bilaterally, with cultures growing Klebsiella pneumoniae . Following bilateral evacuation and 6 weeks of intravenous antibiotics, the patient achieved complete neurological recovery. LESSONS: Subdural empyema should be considered in patients with neurological deterioration following MMA embolization, even in the setting of stable interval imaging and the absence of classic laboratory markers of infection. Although the temporal association with embolization raises the possibility of a procedure-associated mechanism, the route of infection may not always be apparent, and clinicians should maintain a broad differential diagnosis. https://thejns.org/doi/10.3171/CASE26631

Background: Cancer‐related pain remains one of the most debilitating symptoms in patients with advanced malignancy, with a significant proportion experiencing pain refractory to standard medical therapy. Percutaneous cordotomy is an established intervention targeting the spinothalamic pathway and can provide meaningful relief in appropriately selected patients; however, its use has declined and is typically performed in awake patients. Case Presentation: A 54‐year‐old woman with metastatic gallbladder carcinoma presented with severe, unilateral, nociceptive abdominal pain refractory to medical and interventional treatments. Given her limited life expectancy and persistent symptoms, she underwent percutaneous cervical cordotomy. At the patient's request, the procedure was performed under general anesthesia. We achieved excellent localization for safe ablation using intraoperative CT and neuromonitoring guidance. Postoperatively, she reported complete resolution of her primary pain (8–10/10 to 0/10) on postoperative Day 1. She developed expected contralateral “mirror pain,” which was less severe and manageable. Pain relief was sustained during early follow‐up, although later recurrence was attributed to disease progression rather than procedural failure. Conclusion: This case demonstrates that percutaneous cordotomy can be performed safely and effectively under general anesthesia with the aid of intraoperative CT and neuromonitoring. This approach may expand the applicability of cordotomy in carefully selected patients with refractory cancer pain, particularly when patient comfort is a priority.

Background: Brain tumors in infancy and early childhood exhibit distinct clinicopathologic features and outcomes compared to older children. Despite their clinical significance, no study in this region has specifically characterized brain tumors in this age group. This study aimed to describe the clinical presentation, anatomical distribution, histopathology, prognostic factors, and outcomes of brain tumors in children under three years of age. Methods: We conducted a retrospective cohort study at Aga Khan University Hospital, Karachi, Pakistan, including children under three years diagnosed with brain tumors between 2013 and 2024. Demographic data, clinical presentation, tumor characteristics, treatment details, and outcomes were collected. Survival analyses were performed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards regression to identify independent prognostic factors. Statistical analysis was performed using SPSS and STATA, with a median follow-up of 60 months. Results: Over 11.5 years, 50 children under three years were diagnosed with brain tumors. Vomiting (58%) was the most common presenting symptom. Tumors were predominantly infratentorial (62%), with ependymomas (25.5%) and medulloblastomas (23.4%) being the most frequent histological types. Gross total or near-total resection was achieved in 53.1% of cases, while temporary and permanent cerebrospinal fluid diversion were performed in 53.3% and 54% of patients, respectively. Intraoperative complications were rare (4.1%), whereas postoperative complications, including persistent hydrocephalus, occurred in 62% of patients. Adjuvant chemotherapy and radiotherapy were administered to 34% and 26.7% of patients, respectively. The overall mortality rate was 68%, with 12 patients alive at a median Lansky score of 95. Median overall survival (OS) was highest for pilocytic astrocytoma (71.38 months) and lowest in neonates (0–3 months). Kaplan-Meier analyses demonstrated improved OS and progression-free survival (PFS) with a greater extent of resection, absence of metastases, and receipt of adjuvant therapy. Univariate analyses demonstrated associations between survival and patient age, extent of resection, metastatic dissemination, and radiological characteristics. Conclusion: Brain tumors in children under three years are rare and associated with substantial morbidity and mortality. Clinical presentation is non-specific and varies with age. Surgical resection remains the primary treatment, with more extensive resections associated with improved outcomes. Patients receiving adjuvant therapy demonstrated improved survival, although these findings should be interpreted with caution given the retrospective study design. Future research should investigate age-related variations in tumor biology, treatment response, and long-term survival and quality-of-life outcomes.

BACKGROUND: Spinal myoclonus is a rare movement disorder characterized by sudden, involuntary jerking movements arising from segmental spinal circuitry. Treatment is primarily directed toward underlying etiologies or symptomatic control with antiepileptic medications, botulinum toxin injections, or intrathecal therapies. Evidence supporting spinal cord stimulation (SCS) remains limited to isolated reports involving secondary etiologies such as cervical myelopathy or complex regional pain syndrome. The role of SCS in idiopathic segmental spinal myoclonus remains poorly defined. OBSERVATIONS: An 83-year-old woman with medically refractory segmental spinal myoclonus involving the right paraspinal musculature, shoulder girdle, and upper back experienced near-complete resolution of symptoms following thoracic SCS after unsuccessful treatment with multiple medications and botulinum toxin injections. Permanent implantation resulted in sustained symptomatic improvement with complete resolution of jerks at the 7-month follow-up. LESSONS: SCS may represent a promising neuromodulatory strategy for patients with idiopathic segmental spinal myoclonus refractory to conventional therapy. This case expands the limited literature supporting the use of SCS in spinal myoclonus and suggests a potential role for dorsal column neuromodulation even in the absence of structural spinal pathology. https://thejns.org/doi/10.3171/CASE26322

Background Pediatric brain tumors (PBTs) are the most common solid malignancies in children, with an incidence of 5.61 per 100,000 in the United States. Current diagnostic approaches, including clinical evaluation, MRI, and tissue biopsy, are limited by challenges such as pseudoprogression, tumor heterogeneity, surgical inaccessibility, and procedural risk. Liquid biopsy has emerged as a promising, minimally invasive alternative for diagnosis and disease monitoring, particularly with the increasing emphasis on molecular characterization. Methods A systematic review was conducted in accordance with PRISMA 2020 guidelines. Electronic databases (PubMed/MEDLINE, Embase, Scopus, and Cochrane) were searched from inception to June 2025. A total of 831 records were screened independently by two reviewers, with discrepancies resolved by a third. Data extraction was performed independently by two reviewers using a standardized, pre-piloted form. Results Twenty-seven studies encompassing 992 patients were included. Cerebrospinal fluid (CSF) was the most commonly studied biofluid (25/27 studies), demonstrating ctDNA detection rates of 51–100%, particularly in diffuse midline glioma, medulloblastoma, and high-grade glioma. Plasma, evaluated in 11 studies, showed limited sensitivity (< 45%), while urine-based detection was negligible. CSF methylation profiling, reported in five studies, demonstrated concordance with tumor tissue in up to 92% of cases. Additional biomarkers, including CPXM2 and miR-517a, further supported diagnostic utility. Comparative analysis in one study confirmed superior detection in CSF (20%) versus plasma (1.3%) and urine (0%). Conclusion CSF-based liquid biopsy demonstrates strong potential for molecular diagnosis, disease monitoring, and early relapse detection in pediatric brain tumors.

Durrani AD, et al. Brain Tumor Res Treat. 2026 Jul;14(3):147-158. https://doi.org/10.14791/btrt.2026.0002

Cerebellopontine angle (CPA) tumors present surgical challenges due to their proximity to the facial nerve. Despite preservation efforts, facial nerve paresis is a major issue. This study aims to identify key factors affecting facial nerve preservation during microsurgical resection of large CPA tumors in a low- and middle-income countries (LMIC) setting. This retrospective cross-sectional study, conducted at Aga Khan University, included patients who underwent microsurgical resection of large (>3 cm) CPA tumors with House-Brackmann (HB) grades 1-4. Postoperative facial nerve function was assessed using the HB grading system. Data was extracted from medical records and analyzed using SPSS 22. This study analyzed 95 patients (M:F=1:1.16, mean age 44.24±13.71 years) with CPA tumors who underwent microsurgical resection. Common presenting complaints included a complete hearing loss (57.9%), headache (52.6%), and abnormal gait (40%). Preoperative facial nerve function was normal (HB grade I) in 75%, with 19%, 7%, and 2% having HB grades II, III, and IV, respectively. Schwannoma (69.5%), meningioma (16.8%), and epidermoid cyst (10.5%) were the most common diagnoses. Postoperative preservation of facial nerve function was achieved in 73.7% of patients. At six months, HB grades I and II were observed in 64% and 11.5%, respectively, while none had complete facial nerve palsy. On univariate analysis, larger tumor size and higher HB grade correlated with worse facial nerve outcomes (p=0.02). Complications were more frequent in patients with worsened outcomes (72% vs. 38.6%, p=0.004). However, in multivariate analysis, only preoperative HB grade was identified as a predictor. Facial nerve preservation during CPA tumor resection is influenced by intrinsic tumor characteristics, surgical complexity, and patient-specific factors. Detailed preoperative counseling is crucial to set realistic expectations.