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 present an unusual case of steroid responsive inflammatory condition, involving sellar suprasellar region with further ependymal lesions. This is complicated by previous surgery due to pituitary adenoma, not thought to related to inflammatory process. The patient responded well to steroids, but deteriorated due to development of hydrocephalus caused by obstruction due to adhesions. Despite extensive literature review and consideration of all known pathological conditions, it was concluded that the condition represented another inflammatory entity not yet fully characterised. The case also highlights that despite the steroid responsive nature of the condition, the ependymal involvement can result in progressive acute obstructive hydrocephalus with clinical deterioration. This case also suggests close follow-up and early imaging for early detection and treatment of this complication. CASE REPORTThis case report pertains to a 46-year-old male Caucasian who had endoscopic treatment for a pituitary adenona three years previously. He required replacement hydrocortisone and testosterone. Prior to the surgery, he was not known to have any other neurological issues.A year after surgery following minor trauma, he underwent a computed tomography (CT) scan of the head. This confirmed no residual pituitary tumour (Figure 1). He was somewhat non-compliant with endocrine follow-up. Surveillance magnetic resonance imaging (MRI) imaging 2 years following initial surgery demonstrated post-up change with some enhancing tissue scaling the pituitary stalk and hypothalamic region; this was not clearly seen on the previous CT scan, possibly due to different modalities and absence of contrast imaging. Two months later, he developed polydipsia, fatigue and a partial left-sided homonymous visual field deficit. There was progressive confusion with fluent dysphasia and inattention. He was pyrexial. Gaze evoked nystagmus was present to the right. The rest of his examination was unremarkable. MRI brain demonstrated significant progression of the abnormalities seen on the earlier scan with increased enhancing tissue involving the pituitary stalk, hypothalamic area and floor of the 3 rd ventricle, also including the optic chiasm (Figure 2). Associated signal