SummaryA 27-year-old woman developed severe adhesive arachnoiditis after an obstetric spinal anaesthetic with bupivacaine and fentanyl, complicated by back pain and headache. No other precipitating cause could be identified. She presented one week postpartum with communicating hydrocephalus and syringomyelia and underwent ventriculoperitoneal shunting and foramen magnum decompression. Two months later, she developed rapid, progressive paraplegia and sphincter dysfunction. Attempted treatments included exploratory laminectomy, external drainage of the syrinx and intravenous steroids, but these were unsuccessful and the patient remains significantly disabled 21 months later. We discuss the pathophysiology of adhesive arachnoiditis following central neuraxial anaesthesia and possible causative factors, including contamination of the injectate, intrathecal blood and local anaesthetic neurotoxicity, with reference to other published cases. In the absence of more conclusive data, practitioners of central neuraxial anaesthesia can only continue to ensure meticulous, aseptic, atraumatic technique and avoid all potential sources of contamination. It seems appropriate to discuss with patients the possibility of delayed, permanent neurological deficit while taking informed consent. Case reportA 27-year-old woman with no significant medical history and in her first pregnancy underwent spinal anaesthesia for caesarean section for fetal compromise at another hospital at 42 weeks' gestation, after going into spontaneous labour. With the patient sitting, the skin over the L4-5 interspace was cleaned once by a consultant anaesthetist using a SOLU-I.V.Ò MAXI swabstick (Solumed, Laval, Canada) impregnated with 2% chlorhexidine gluconate and 70% isopropyl alcohol. There was no delay between opening the swabstick packaging and its use on the patient's skin. It is not clear whether the swabstick and its packaging were disposed of immediately. The prepared area was allowed to air-dry for 3 min before a 24-G needle (Becton, Dickinson & Company, Franklin Lakes, NJ, USA) was placed at L4-5 on the first attempt by a consultant anaesthetist wearing a sterile surgical gown and gloves, mask and hat, using an aseptic technique. After aspiration of free-flowing, clear cerebrospinal fluid (CSF), 2.5 ml bupivacaine 0.5% with 12.5 lg fentanyl was administered over approximately 15 s. A few seconds after the end of the injection, the patient complained of severe, burning pain in the lower back radiating into the legs bilaterally, worse on the right than the left. The pain began to recede as the block took effect and this was formally assessed 10 min after the

Aims. Emergency debridement has long been the standard of care for open fractures of the tibia as infection is an important complication. The timing of operative debridement can be debated. We review open fractures of the tibia and compare infection rates in those that were operated on within and after 6-hours. Method. 103 consecutive open fractures of the tibia were reviewed. The data was analysed retrospectively with regard to severity of fracture and incidence of infection. Infection rates over a three-month period were compared between the two groups. Results. 12 (11.6%) patients developed an infection within the first 3 months of injury. 7 of which were taken to theatre within 6-hours, and 5 after 6-hours. No significant differences were found between these two groups. Conclusion. There is no significant difference in timing of surgery. Initial basic interventions may play more of a role in limiting the risk of infection.

Level III--retrospective comparative study.

In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.

Patients with increased protein levels in CSF are at a high risk of VPS blockage. In these patients, temporary measures should be employed until CSF protein levels decrease.

The most important changes have occured in the fields of neuro-oncology, vascular neurosurgery and spinal surgery. Inter-specialty collaboration is establishing itself as a model of care. These data may guide resource allocation for a population increasing both in number and in age.

Neurological complications of the prone position have been well documented. Post-operative paraplegia and neurological deterioration unrelated to the site of surgery after proning in spinal surgery is a rare but potentially devastating complication. We describe the case of a 47 year old female who underwent an L4/5 discectomy and posterior instrumented fusion. A few hours after surgery she developed bilateral lower limb weakness with a T11 sensory level. Post-operative MRI revealed an acute disc herniation at the T11/12 level with associated spinal cord compression. This was not present on the pre-operative imaging. A subsequent T11/12 discectomy and instrumented fusion was performed and the patient's motor and sensory function returned to normal.

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