Lawsonella clevelandensis causing spinal subdural empyema.

Lawsonella clevelandensis is a recently described species and genus of bacterium in the Corynebacterineae suborder which is Gram-stain positive, partially acid-fast and anaerobic. Very few cases of human infection due to this organism are described and here we seek to add to the limited medical literature. We report the case of a 2-year-old girl who presented with an infected spinal dermoid cyst secondary to Lawsonella clevelandensis which required surgical drainage and a long course of antibiotics. We encountered diagnostic and therapeutic difficulties because this is a fastidious organism which was difficult to culture and ultimately required molecular detection and identification. To the best of our knowledge, this is only the seventh reported case of Lawsonella clevelandensis causing human infection worldwide and the first in the UK. This is the first reported case of Lawsonella clevelandensis infection in a child and the second reported case of this organism causing spinal infection.

Head trauma and cavernoma haemorrhage - the importance of causality.

Cavernomas are common, benign vascular lesions that affect the brain. Five-year bleeding risk is approximately 3.8% for asymptomatic lesions. Non-spontaneous, traumatic cavernoma haemorrhage has been seldom reported. We present the case of a 49-year-old male with multiple traumatic brain injuries who was managed conservatively. Initial imaging was suggested, and reported as, a traumatic brainstem haemorrhage. However, after resuscitation and a follow-up MRI scan, the diagnosis of a cavernoma bleed was confirmed in keeping with his mild neurological syndrome. This case illustrates the old dictum to treat the patient and not the scan. It serves as one of the few reported cases of post-traumatic cavernoma bleed, and showcases the difficulty in ascribing haemorrhage to spontaneous or traumatic aetiology. We recommend having a low threshold to investigate further in these unusual situations.

Large bowel obstruction and perforation secondary to endometriosis complicated by a ventriculoperitoneal shunt.

A 36-year-old lady, with a past medical history of hydrocephalus requiring a ventriculoperitoneal (VP) shunt, was admitted with symptoms and signs of large bowel obstruction. Her condition worsened and she underwent laparotomy, where she had faecal peritonitis secondary to a perforated sigmoid colon. The shunt was contaminated with faeces leading to postoperative shunt infection and meningitis. Histology of the resected sigmoid colon revealed endometriosis at the site of perforation. Endometriosis is a rare cause of large bowel obstruction and literature review has found only two other cases of perforation because of endometriosis not associated with pregnancy. No case has been reported involving the concurrent surgical management of a contaminated VP shunt. We discuss the rarity of large bowel perforation and obstruction because of endometriosis, and the complications and management of VP shunts.

An unusual presentation of thoracic cord compression by a dorsal arachnoid cyst in a 14-month-old boy. A discussion of the case and review of the literature.

Spinal arachnoid cysts are a rare cause of spinal cord compression in children and presenting symptoms may be subtle. We present a neurologically intact 14-month-old boy who presented with pain and postural irritability from a thoracic arachnoid cyst.

Spontaneous umbilical CSF fistula in an adult as a complication of a ventriculoperitoneal shunt.

Ventriculoperitoneal (VP) shunt is the most commonly used CSF shunt in the modern era and widely accepted for the management of hydrocephalus. Numerous abdominal complications have been reported in the literature. Spontaneous umbilical fistula from VP shunt, although uncommon, has been reported previously in children, but never in an adult. This is a case report on an adult who was treated for spontaneous umbilical fistula at our unit.

The use of chemotherapy to facilitate surgical resection in pleomorphic xanthoastrocytoma: experience in a single case.

The use of noncytotoxic chemotherapy as an adjuvant treatment to permit resection of a pleomorphic xanthoastrocytoma (PXA) is described. A 6-year-old girl with a large right occipito-temporo-parietal lesion presented with signs and symptoms of raised intracranial pressure. An initial attempt at resection was halted because of excessive blood loss, and tumour embolisation was not feasible as no suitable vascular pedicle was identified. Two cycles of vincristine and carboplatin were given, and these decreased the vascularity of the tumour allowing subsequent complete macroscopic resection 9 weeks later. The use of chemotherapy to decrease the vascularity of the tumour by way of its antiangiogenic effects is discussed.

Neuroendoscopic third ventriculostomy in dysmorphic brains.

Neuroendoscopic third ventriculostomy (NTV) has superseded shunting as the treatment of choice in non-communicating hydrocephalus. Intracranial developmental anomalies have been considered to be relative contraindications for this procedure. We present one patient with a Dandy-Walker malformation and another with septo-optic dysplasia who presented with hydrocephalus. An NTV was performed successfully in both patients using a flexible neuroendoscope and utilising transendoscopic Doppler ultrasound to ensure a safe target area for ventriculostomy.

Telephone advice for neurosurgical referrals. Who assumes duty of care?

The rising rate of litigation against all specialities provides an incentive to develop risk management strategies. Much of a neurosurgeon's workload is telephone advice, which is rarely documented formally. This leaves us vulnerable to other clinicians' interpretation of our advice, their record of our conversation and poor accuracy of recall by both parties. We performed a prospective study of all telephone conversations with referring clinicians over 1 year, in order to assess the quality of information transfer. We found that the information received was often inaccurate, documentation of our given advice was poor, and criticism of neurosurgical care was unfounded. We have developed a proforma to be faxed back to the referring team. This will ensure that the information received, and the advice given in return, is recorded formally by both teams. Only time will tell if a joint record such as this will provide sufficient defence against litigation.

Primary cerebral non-Hodgkin's lymphoma: problems with diagnosis and development of a protocol for management.

The prognosis for primary cerebral non-Hodgkin's lymphoma has improved markedly in the under-70 age group with the introduction of combined chemotherapy and radiotherapy. A review of our patients has revealed difficulty in obtaining definitive histology initially in 21% (9/43). We investigated the role of corticosteroids in these patients and found an idiosyncratic response in that there was no significance either of the cumulative dose (p > 0.424) or the length of treatment (p > 0.453) with the observed regression of lymphoma with corticosteroids. In order to avoid indiscriminate corticosteroid administration we have formulated a management protocol the entry point for which is a patient with enhanced computered tomography appearances of primary cerebral lymphoma.

A view on the science: physical anthropology at the millennium.

The year 2000 marks the onset of the 21st century. In this transitional year, prominent physical anthropologists will provide brief reflections on our discipline, including what attracted them to it, and their views on the directions our discipline may pursue as we enter, in January 2001, the third millennium.

Terminal Myelocystocele:an unusual presentation.

Terminal myelocystocele is an unusual form of occult spinal dysraphism. It consists of a cystic dilatation of a low-lying terminal cord herniated posteriorly through a skin-covered lumbosacral spina bifida. An arachnoid-lined meningocele, continuous with the spinal subarachnoid space, is traversed by the hydromyelic cord. Clinically, this presents with a skin-covered lumbosacral mass, but often no neurological deficit is present. We present a case of terminal myelocystocele in a child born without deficit and without an obvious back mass. Diagnosis was delayed until sphincter disturbance and lower limb inequalities developed. We discuss the presentation, imaging and operative findings in this case.

Prothrombin complex concentrate for oral anticoagulant reversal in neurosurgical emergencies.

The incidence of spontaneous intracranial haemorrhage has increased markedly in line with the increased use of oral anticoagulant agents. Recent guidelines for reversal of this acquired coagulation defect in an emergency have been established, but they are not adhered to in all centres. Our unit is referred between 20 and 60 patients per year (1994-1999) who are anticoagulated and require urgent neurosurgical intervention. In order to investigate this, we performed a prospective study using prothrombin complex concentrate (PCC). PCC was given to the first six patients with intracranial haemorrhage admitted to the neurosurgical unit requiring urgent correction of anticoagulation (Group 1) and compared with patients receiving standard treatment with fresh frozen plasma and vitamin K (Group 2). Mean International Normalised Ratios of Group 1 were 4.86 pretreatment and 1.32 posttreatment, and of Group 2 were 5.32 and 2.30, respectively. Results for complete reversal and reversal time were significant for PCC with p < 0.001. We recommend PCC for rapid and effective reversal of warfarin in life-threatening neurosurgical emergencies.

The fate of the cerebrospinal fluid after neuroendoscopic third ventriculostomy.

This paper describes the case of a 9-year-old girl with a posterior thalamic/pineal region lesion and secondary obstructive hydrocephalus. The hydrocephalus was treated by neuroendoscopic third ventriculostomy (NTV), and she underwent simultaneous transendoscopic biopsy. The tumour biopsy was haemorrhagic, but the bleeding settled with constant irrigation. The patient remained neurologically unchanged, but subsequent imaging revealed an asymptomatic thoracolumbar spinal subdural haematoma thought to be due to blood flowing out through the NTV into the subdural space. This demonstrates the subdural location of the cerebrospinal fluid after NTV.

Diffuse brain stem glioma. A review of stereotactic biopsies.

The diagnosis and management of diffuse brain stem gliomas (DBSGs) remain a challenging problem for the neurosurgeon and neuro-oncologist. Opposing views on the necessity for biopsy have emerged over the last decade. Open biopsy, with its prohibitive morbidity and mortality, has been replaced by stereotactically guided biopsy, with markedly reduced risk. This has been paralleled by improvements in imaging techniques and diagnostic accuracy, which has created reluctance to endorse diagnostic biopsies coupled with the potential of nonrepresentative samples from a heterogeneous tumour mass. For typical DBSGs biopsy is now accepted as unnecessary. We performed a retrospective analysis of radiologically and histologically proven DBSGs in 18 children to assess both morbidity and reliability of our stereotactically guided biopsy procedure.

Occipital condyle fracture with peripheral neurological deficit.

A 24-year-old woman sustained a type III Anderson and Montesano fracture in a road traffic accident. Acute respiratory stridor, multiple cranial nerve palsies and right upper limb neurological deficits associated with a C1 to T2 extradural haematoma were unique features of this case. The patient made a full and uncomplicated recovery with conservative management.