Arachnoid cysts are lined by arachnoid membranes and filled with cerebrospinal fluid. Etiologically, they are thought to be due to maldevelopment of the arachnoid or secondary to trauma or infection. Postnatally, many are asymptomatic and remain quiescent for years, although others expand and cause symptoms by compressing adjacent brain and/or expanding the overlying skull. Being congenital, it should be possible to identify them in the fetus, and this has proved to be so. But are they anatomically similar and do they behave the same as those detected postnatally? Fifteen fetuses with fluid-filled cysts were identified from the database of the Fetal Management Unit at St. Mary's Hospital in Manchester. Five were diagnosed at or before 20 weeks of gestation, 4 between 21 and 30 weeks, and 6 at 31 weeks or more. Thirteen cysts were in the supratentorial compartment, and 2 in the posterior fossa. Eleven fetuses were delivered, and 4 pregnancies were terminated. One of the born children had Pallister-Hall syndrome and died on day 19, and another had Aicardi's syndrome, is retarded and has fits, 1 with a posterior fossa cyst developed hydrocephalus in utero and was delivered early for the insertion of a ventriculoperitoneal shunt, he is moderately mentally delayed. Of the remaining 8 children, 1 has been lost to follow-up, and 7 appear to be reaching their early milestones on time. The 4 terminated fetuses had a postmortem examination, 2 did not have arachnoid cysts; 1 had an expanding glioependymal cyst which had destroyed most of the cerebral hemispheres, and the other had a sagittal sinus thrombosis with extensive cavitation of one cerebral hemisphere. The diagnosis of an arachnoid cyst in the fetus can be difficult and may be confused with other fluid-filled cysts.

We present a case of cervical intramedullary sarcoidosis. A 56 year old woman presented with progressive paraesthesia affecting the lower limbs. MRI revealed an intramedullar lesion from C4-C7. A laminectomy and subtotal resection was carried out for this presumed intramedullary tumour. Pathology revealed this to be a granulomatous lesion with features indicative of sarcoidosis. Postoperatively, there was no change in her neurological function and her symptoms improved with steroid therapy.

Osteomyelitis of the odontoid process is a rare disease and Staphylococcus aureus is the usual causative organism. We present a case caused by a synergistic infection with Staphylococcus aureus and Proteus mirabilis, which has not been reported previously. A high index of suspicion is required for diagnosis, and early institution of broad antimicrobial therapy, including agents active against gramnegative organisms, is mandatory.

Introduction: One of the major errors that can be encountered by a spinal surgeon is operating at the wrong level/side. However, wrong-level spinal surgery is considered a 'never-event' and is under-reported. Many surgeons have traditionally adopted the technique of palpating or "counting" from L5-S1 to determine the operative level in lumbar spine procedures without necessarily the use of intraoperative X-ray control. Most surgeons these days; however, use X-rays or fluoroscopy during the surgery. There is no universal standard operating procedure (SOP) for the use of X-rays or fluoroscopy during spinal surgery and the compliance of the surgeons for any local SOP is unknown. Aim: The audit primarily intended to check the compliance with an established local SOP using X-ray to identify lumbar spinal level. We also determined the accuracy of lumbar spine level marking by palpation. We also tried to quantify the intra-operative error rate following pre-operative X-ray level marking. Overall, the optimum role of X-rays was determined for adequate level of lumber decompression. Methods: The audit was performed as a prospective clinical audit within a single neurosurgical department. Data collected from theatre logbook, medical notes and picture archive and communication system (PACS). An established local SOP for use of X-rays during spinal surgery was used as a benchmark to audit local practice. Cycle 1: Every lumbar discectomy and decompression from June to November 2015 (6 months) was obtained. The findings were presented in our local clinical effectiveness meeting with the aim check local practice and suggest improvements. Cycle 2: Re-audit a further 6 months, December 2015 to May 2016, to see the significance of the change implemented. Results: In the first cycle, one patient did not receive pre-operative X-ray. While all other patients received pre-operative X-rays, the number of exposures was available in only 71% of patients, out of which 39% required one exposure, 43% required two exposures, 16% required three exposures and 2% required four exposures. Twenty eight cases (13.9%) were recorded to have intra-operative X-ray level checked due to doubt, out of which 22 cases were found to be on an incorrect level. In the second cycle, all patients received pre-operative X-rays and the number of exposures was recorded for all, out of which 52% required one exposure, 32% required two exposures, 13% required three exposures and 3% required four exposures. Twenty cases (9.7%) were recorded to have intra-operative X-ray level checked due to an arising doubt, out of which only 7 were found to be on an incorrect level.

We report a patient with multiple cranial nerve and lumbar spine nerve root melanotic schwannomas, a rare variant of schwannoma, with raised intracranial pressure. Possible pathophysiology of the raised intracranial pressure by decreased CSF resorption due to blocked spinal lymphatics and other mechanisms is discussed.