Introduction Giant herniated thoracic discs (GHTD) remain a surgical challenge. When combined with calcification, these discs require altered surgical strategies and have only been infrequently described. Our objective was to describe our surgical approaches in the management of calcified GHTD. Methods This was a retrospective cohort study of all patients with calcified GHTD operated between 2004 and 2012. Data were collected from review of patients' notes and radiographs and included basic demographic and radiological data, clinical presentation and outcome, operative procedure and complications. Results During the study period, there were 13 patients with calcified GHTD, including 6 males and 7 females (mean age 55 years, range 31-83 years). The average canal encroachment was 62 % (range 40-90 %); mean follow-up 37 months (12-98). All patients were treated with anterior thoracotomy, varying degrees of vertebral resection, removal of calcified disc and with or without reconstruction. The average time for surgery was 344 min (range 212-601 min) and estimated blood loss 1,230 ml (range 350-3,000 ml). Post-operatively, 8 patients improved by 1 Frankel grade (62 %), 2 improved by 2 grades (15 %) and 3 did not change their grade (23 %). The complication rate was 4/13 (31 %; 3 patients with durotomies (2 incidental, 1 intentional) and 1 with recurrence). Discussion Calcified GHTD remain a surgical challenge. Anterior decompression through a thoracotomy approach, and varying degrees of vertebral resection with or without reconstruction allowed us to safely remove the calcified fragment. All patients remained the same (23 %) or improved by at least 1 grade (77 %) neurologically, without radiographic failure at final follow-up.

Intrathecal baclofen (ITB) is a well-established method of treating spasticity in children with cerebral palsy. In our series, eight children with primary or dystonia secondary to cerebral palsy have benefited from ITB. The observations in this paper are subjective and based on the carer's impressions, but have confirmed the role of ITB in dystonia. Children with dystonia secondary to cerebral palsy benefited most and ITB can be used in these as a single treatment modality. The approach is different in dystonia secondary to cerebral palsy, where ITB can be used to palliate the spastic component, but other methods are necessary to treat the primary disease. We currently have three children in our series, where ITB in conjunction with deep brain stimulation (DBS) was used with satisfactory results.

Continuous intrathecal baclofen infusion (CIBI) for spasticity of spinal and cerebral origin has been practised for over two decades. More recently, it has been used for severe spasticity of cerebral origin in children. Intrathecal baclofen (ITB) appears most beneficial in severe spastic tetraparetics or tetraplegics, but the evaluation of the outcome of ITB and the benefit of the treatment are largely subjective. The evidence base for this treatment has been questioned, in particular for ambulant children, mainly because of the lack of objective outcome measures. Fifty-two spastic tetraparetic children have been treated by this method in Nottingham, from 1998 to 2003. This represents a large homogeneous series of CIBI in children with severe spasticity of cerebral origin. We carried out a prospective audit of our experience, morbidity and observations during that period. We identified that the lack of a suitable scoring system for the evaluation of effectiveness and benefit is a drawback. As a result of these observations a multicentre randomized controlled trial on ITB in tetraplegia-paresis and ambulant children is advocated.

Until recently, idiopathic anterior spinal cord herniation was thought to be vanishingly rare. It is an increasingly recognized, readily treatable, condition causing progressive thoracic myelopathy. We have operated on five cases and know of two other patients locally who are as yet undecided on surgery. We are aware of several other unpublished cases in the UK. The syndrome presents typically in middle age with a history of stepwise slowly progressive mid-thoracic anterior hemicord dysfunction characterized by hemianalgesia below the affected segment followed by asymmetric lower limb hypertonia, with initial sparing of posterior column sensation, that progresses through paraparesis to complete paraplegia. The radiological findings, although subtle, are equally typical and surgical repair is easily effected. With increasing clinical and radiological awareness, we believe the apparent incidence of this condition will increase. Idiopathic anterior spinal cord hernia is more common than currently appreciated, and should be positively considered and excluded in every case of progressive thoracic cord dysfunction.

Stereotactic brain biopsy is the current gold standard procedure to obtain a neuropathological diagnosis. An audit of 207 stereotactic cases, between January 1997 and December 2000 was carried out. The aim was to determine the optimum number of target sites required to make the final diagnosis and thereby set up recommendations for future practice. The overall diagnostic success rate was 89.3%. A significant positive correlation between the number of targets taken and the probability of achieving the final diagnosis was seen. In a subset of glioblastoma cases 96.1% of the tumours could have been confidently diagnosed on the basis of any two of the targets chosen, although often more targets were taken than this. The recommendations made by the audit were: (i) in cases where it is suspected the lesion does not require grading, one target site should be taken and further sites should only be taken if the first proves to be non diagnostic; (ii) in suspected glial series tumours, two targets should be routinely taken, with further sites taken only if these prove inconclusive on intraoperative smear.