Cerebral abscess is an emergency requiring urgent drainage via craniotomy or burrhole aspiration. We examine whether initial method of drainage affects outcome and important characteristics in patients with cerebral abscess. This is a retrospective analysis of 62 patients operated on in our unit with a loculated infected cerebral collection in the years 2003-2007 inclusive. Full statistical analysis was performed using data appropriate tests. Burrhole and craniotomy groups were evenly matched with no difference in any demographic factors. Surgical method made no difference to rate of re-operation (p = 0.276), antibiotic duration (p = 0.648), discharge GCS (p = 0.509), length of stay (p = 0.647) or GOS (p = 0.968). There was a trend to worsened outcome with delay to surgery (p = 0.132) with delayed patients requiring longer hospital stays (p< or = 0.005). Patients requiring a longer antibiotic duration had worse outcomes (p < or = 0.005). Surgical method did not have a significant effect on outcome, so burrhole aspiration with its advantages in terms of speed and scale of surgery should be strongly considered. Delay had an adverse affect, so operation should be as expeditious as possible whenever the differential diagnosis includes abscess, diagnosis of which may be aided by advanced magnetic resonance imaging techniques.

Case presentationMP is a 36-year-old man who had an upper lumbar myelomeningocoele closed on the ®rst day of life. He had a degree of hydrocephalus but never required any treatment for this. As a child there was a marked disparity in lower limb function ± with the right leg near normal but with the left leg spastic, very weak and shortened. He had undergone left adductor tenotomy and psoas transplant aged 10 years and had a left femoral fracture at 16 years but remained well motivated and was mobile with elbow crutches and calipers. He had a neurogenic bowel, a neuropathic bladder with a suprapubic catheter, and preserved sexual function. Mobility and function otherwise were generally static over the next 20 or so years.At the age of 35 years he presented to his GP with a year's history of worsening back pain, especially severe at night, disturbing sleep. This was associated with loss of sensation of the previously normal right lower limb. He was referred to a Spinal Orthopaedic Clinic and the referral was prioritised as`routine' with an expected waiting time of 53 weeks. Twelve months later his pain and sensory loss had worsened and he was having di culty weightbearing on the right leg: his outpatient appointment was expedited. In the interim he had a fall fracturing his left tibia. By chance, he was seen for this at the Fracture Clinic by an Orthopaedic Surgeon with a Paediatric interest; he reported an abrupt marked deterioration in power in the right leg some 3 weeks earlier such that he could no longer walk and was admitted for investigation and a neurosurgical opinion. By now he had no power or sensation in the left leg, and in the right leg had Grade 2 hip¯exion, Grade 3 knee extension, no power at the ankle and a suspended sensory loss from L3 to S1. MR of the neuraxis demonstrated a moderate supratentorial hydrocephalus and a Chiari II malformation with the tonsils down to C2 though with no compression at the foramen magnum. In the spine (Figures 1 and 2) there was an extensive intradural mass lesion lying posterior to the neural tissue at the level of the myelomeningocoele repair and a moderate size thoracolumbar syrinx above this. The di erential diagnosis of this lesion was felt to be either a dermoid cyst or a tumour. Comments by participantsWhat is your di erential diagnosis? M Spencer (General Practitioner) points out that he sees very few cases of spina bi®da at any age and ®nds this di cult, but highlights possibilities such as a problem arising as a direct late consequence of his myelomeningocoele or secondary mechanical or musculoskeletal consequences due to abnormal posture and use of the lower body. As such he would consider disc prolapse as well as`non-back' causes of back pain on the di erential including urinary tract infection and constipation.DL Douglas (Orthopaedic Surgeon) also pays heed to incidental pathologies adding meningioma or AV malformation to the list. He mentions that patients with spina bi®da and asymmetric neurology frequently have back deformities such as scoliosis. He w...

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ObjectivesTo increase the amount and quality of didactic teaching by commissioning an in-house Diploma course using distance-learning methodologies to supplement regular departmental teaching sessions.DesignWeb-based course consisting of 9 modules covering the breadth of neurosurgical topics. A Diploma was conferred by the Head of Service upon successful completion of all modules.SubjectsTo date, eleven learners (junior doctors at F1/F2/SHO level) have started the Diploma, including doctors from outside our department.MethodsLearners download a module, dedicate a period of self-study and then discuss the module with their Tutor. To complete a module, a learner would be expected to demonstrate to the Tutor that their knowledge was at ST2 standard as described in the neurosurgical curriculum. Assessment of modules was documented on learners’ existing portfolios.ResultsBy way of feedback, all learners (100%) strongly agreed that the Diploma was useful for their day to day job, that it helped understand management of acute neurosurgical problems, that it was interesting, that they would recommend it to a friend/colleague and that support received from the Course Tutor was helpful.ConclusionsLearners reportedly enjoyed the self-directed, flexible aspect of the Diploma and found that it promoted interactive discussions with registrars and consultants. Feedback obtained externally through HEE and GMC was highly praiseworthy of the Diploma. We intend to continue to offer this course.