A 48-year old man presented with back pain that was resistant to treatment. An MR scan showed spondylolisthesis at L4-5 and narrowing of the exit foraminae. He had a posterior fusion which did not relieve his symptoms. He continued to have back pain and developed subcutaneous nodules in both forearms. Biopsy from the skin revealed cutaneous sarcoidosis, and one from the lumbar spine showed sarcoidosis granuloma between the bone trabeculae. A CT scan of the abdomen and chest revealed axillary lymphadenopathy, mediastinal enlarged nodes, apical nodular nodes and splenomegaly. The patient was started on large doses of methotrexate and steroids. His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.

We would like to present a rare case report describing a case in which new-onset tonic-clonic seizures occurred following an unintentional durotomy during lumbar discectomy and decompression. Unintentional durotomy is a frequent complication of spinal surgical procedures, with a rate as high as 17%. To our knowledge a case of new onset epilepsy has never been reported in the literature. Although dural tears during surgery and CSF hypovolaemia are thought to be the main contributing factors, one postulates on the effects of anti-psychiatric medication with epileptogenic properties. Amisulpride and Olanzapine can lower seizure threshold and should be used with caution in patients previously diagnosed with epilepsy. However manufacturers do not state that in cases where the seizure threshold is already lowered by CSF hypotension, new onset epilepsy might be commoner. Finally, strong caution and aggressive post-operative monitoring is advised for patients with CSF hypotension in combination with possible epileptogenic medication.

Neck of femur fractures predispose patients to venous thromboembolism (VTE). NICE has issued guideline 46 to reduce this risk through the use of antithrombic agents. We audited our department's VTE practise by reviewing the clinical notes of 123 consecutive patients with no exclusions. We found our compliance to be a low 6%. We also found that patients were likely to be given low molecular heparin (LMWH) only during their hospital stay. Reasons for the low adherence were probably secondary to confusion caused by the multiple thromboprophylaxis protocols used in our department. The correlation between duration of heparin administration and length of hospital stay was due to logistical difficulty in administering VTE prophylaxis out of hospital setting.

Failed back surgery syndrome is defined as increased or persistent pain following spinal surgery. Despite a relatively high incidence of failed back surgery syndrome (20%), patients may not be counselled regarding this complication pre-operatively. The Academy of Medical Royal Colleges has provided the Benefits, Risks, Alternatives and doing Nothing Toolkit to guide clinical discussions during the consent process. A 46-year-old female experiencing chronic lower back pain since 2003 suffered an exacerbation in 2015. Imaging identified non-compressive disc bulges. She was not put through the low back pain pathway as recommended by NICE and underwent spinal fusion in 2017. She continues to experience severe pain 54 months postsurgery. When considering spinal surgery, the risk of failed back surgery syndrome should be discussed with patients. Both clinicians and patients can use the BRAN toolkit to ensure open and transparent discussion prior to any intervention.

Purpose: To evaluate the outcome following internal fixation of olecranon fractures using the techniques of tension band wiring and plating. Design: retrospective evaluation. Setting: regional trauma center. Patients and Methods: 48 consecutive patients with fractures of the olecranon were treated over a 20-month period (May 1993 to December 1994. Analyses of the results were based on the medical records, preand postoperative radiographs of all 48 patients and clinical review of 39 patients at a mean follow-up of > 2 years (range 28-48 months). Intervention: 25 fractures were fixed using the AO tension band-wiring technique and 23 were fixed with a plate; the selection of method was based on agreed radiologic fracturepattern criteria. Main outcome measurements: radiographic evaluation of the quality of reduction was carried out using a grading system. Clinical outcome was assessed using the Broberg & Morrey functional rating index. Results: Clinical evaluation of 39 patients was carried out. In the tension band-wiring group, 17 (85%) patients had an excellent or good outcome and eleven (55%) patients underwent a second procedure for symptomatic metalwork. In the plating group, 16 (84%) patients had an excellent or good outcome and two (11%) patients underwent a second procedure for symptomatic metalwork. The latter group had more complex and associated fractures and included the only poor result. Conclusion: Internal fixation of fractures of the olecranon results in good functional outcome. Patients who have tension band wiring more often require a second procedure for removal of symptomatic metalwork.