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A case is reported in which chemical meningism occurred after lumbar facet joint block with methylprednisolone acetate and bupivacaine. This complication was probably due to inadvertent dural puncture. The use of steroids in facet joint injections is questioned. Key wordsPain; chronic. Complications; chemical meningitis. Anatomy; lumbar facet joint. Hormones; corticosteroids. Case historyA 44-year-old woman presented to the Pain Management Clinic with a 20-year history of low back and right buttock pain with occasional radiation to the right knee. She had first injured her back as a midwife whilst assisting at a delivery. Conservative treatment for the pain was not successful and she developed progressive numbness of her right leg. A laminectomy and removal of L, , and L, S, discs was performed. The numbness in her leg gradually resolved but she continued to have intermittent episodes of severe back pain. On examination she was found to have reduced straight leg raising of 40" on the right side but no other abnormal neurological signs were found. Computerised axial tomography (CT) and magnetic resonance imaging (MRI) showed degenerative disc disease at L, , , with a posterior bulge of the annulus without root compression. Facetal joint hypertrophy was also shown.A series of diagnostic blocks with bupivacaine and methylprednisolone acetate were performed, which produced pain relief for 6 weeks, but by 4 months her symptoms had returned. Facet joint blocks were repeated on the right at L,, and L,,, together with a block of the medial branch of the posterior ramus of L,. A total of 12 ml 0.5% bupivacaine and 80 mg methylprednisolone acetate was used. The patient complained of severe pain in the leg during the injection of the posterior ramus. The injection was discontinued and the needle withdrawn, with resolution of the pain. Fifteen minutes after the procedure she complained of a mild parietal headache and a burning sensation throughout her body. She was flushed and had a tachycardia but remained normotensive. She had a temperature of 37.5"C. Bed rest, fanning and aspirin therapy was recommended overnight. The next day she had occipital headache, mild photophobia, marked neck stiffness and a temperature of 38.5"C. Neurological examination was otherwise normal. A full blood count, biochemistry, blood and urine cultures and chest X ray were negative. Chemical meningism was diagnosed but the decision was made not to perform a lumbar puncture unless there was evidence of neurological deterioration.The patient was given intravenous fluid therapy and codeine phosphate was prescribed for her headache. She developed a sensonneural hearing deficit in her right ear which lasted 2 days. She complained of blurred vision and a nonspecific skin pruritus.

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IT would not be an exaggerationi to say that today , in England and Wales, tllere are 106,990 individuals afflicte(d with tuberculosis of the laryinx. This figure is arrived at in the following maniner: In the year 1923 the deaths from pulmonary tuberculosis amounited to 32,097.* Now, statisticians are of opinion that for every single case which succumbs durinig a year there are teni others still suffering from it; tllis gives us 320,670 as the niumber of consumpti-e invalids in one year. Of these 320,970 patients the l)roportion who must have a larynigeal complication is at least one in three; andl so we arrive at 106,990 as a modest estimate of the niumber of those 'whlo, in this country today , require relief or cure for tuberculosis of the larynx. Of every ten persons born one is going to die of tuberculosis, ald, as a rule, lie will succumb wlhile in the prime of life. Tuberculosis is the most importanit disease with whiclh humanity lhas to cope. There is nio otlher specific disease so common in the larynx. As the 106,990 cases in this country today must look prinicipally to the physiciani for guiidance and help, it is well worth whlile considering wlhat assistance in his task can be offered by a larynigologist who, during a period of ten years, has carefully watched the progress of 477 inistances of laryngeal disease, in 2,541 patients with piulmolnary tuberculosis.' Proportion of Laryn geal Cascs in Pubnmonary Tuibercuilosis.

TE BRiiTTi 75& my1 hands proved ratjier disappointinig, anid it seemis, to fail most, ofteni ill advanced d cases iiI which oine was1i lhoping tIhe m1,o.st froni it. Cocaiinization of the spheuo-,piihitine ganglion, as in. the S1in-eder bpc&ratiou for etlhin'oidal disease, is sai4d to abolissh the reflex pain' in' tlh eiar, but the effects are naturally o1ily tIrallnsitory. Couglh, which may be 'due to th`e local klaryngeal conciditioll, is ofteli most-s-atisfactorilv relieved by the intratiraclheal iinjectioni of oily solutions. A la.rgoe-variety of (hugs halv n aturally Leen emiployved, but a 3 per cent. solulotion of creosote ini olive oil iwill be founjid to be as effective as ainy ini relieviing the irritatioin that seems to produce the couglh. Tllere is one oily solutioni for local application that has within recent Ies been st ongly.-advocated in Anmerlica,