Transsphenoidal surgery.

Transsphenoidal surgery has evolved much over nearly 100 years. Initially operations were performed often without any input from endocrinology colleagues, and without preoperative imaging, operative magnification and illumination. Advances in the understanding of the biology of pituitary tumours, close co-operation between endocrinologists, surgeons and oncologists, and huge advances in imaging and surgical techniques have led to the evolution of the current transsphenoidal operation to the pituitary fossa to the point where a 'cure' is often possible with low complication rates. The indications, contraindications of transsphenoidal surgery will be discussed, together with nature of the surgical approach and how it can be applied to particular pituitary tumours and suprasellar lesions.

Thoracic arachnoiditis, arachnoid cyst and syrinx formation secondary to myelography with Myodil, 30 years previously.

Spinal arachnoiditis can rarely occur following irritation from foreign body substances, including certain oil based contrast agents used for myelography. We describe a patient with thoracic arachnoiditis, arachnoid cyst and syringomyelia, 30 years following a myelogram with Myodil. A 62-year-old female presented with chronic thoraco-lumbar back pain, a spastic paraparesis and sphincter disturbance. She had undergone a myelogram with Myodil, 30 years previously for investigation of back pain. A MRI scan revealed evidence of arachnoiditis, thoracic syringomyelia (T6-T8) and an anteriorly placed, extramedullary, arachnoid cyst at T10-T12, compressing the cord. At surgery, T7-T10 thoracic laminectomies were carried out and syringo- and cysto-subarachnoid shunts were inserted. At 12 months follow-up, the sphincter disturbance, lower limb weakness and mobility problems had almost resolved. Although, the use of oil based contrast agents such as Myodil has been discontinued, the present case illustrates some of the rare sequelae of its use, manifesting decades later. Aggressive surgical intervention produced symptomatic benefit.

Trigeminal neuralgia secondary to Chiari's malformation--treatment with ventriculoperitoneal shunt.

BACKGROUND: Trigeminal neuralgia (TN) is most commonly related to vascular compression of the trigeminal nerve. Trigeminal neuralgia associated with Chiari's malformation and associated hydrocephalus are rare. CASE DESCRIPTION: A 31-year-old male presented with classical TN affecting the mandibular division of the right trigeminal nerve. His symptoms were poorly controlled with increasing doses of carbamazepine. Magnetic resonance imaging scan of brain revealed Chiari's type I malformation and associated hydrocephalus. Approximately 1 month after insertion of a programmable ventriculoperitoneal shunt, his TN resolved. CONCLUSIONS: Chiari's malformation and hydrocephalus are rare associates of TN. The pathophysiology of TN in these cases may be due to neurovascular conflict, related to raised intracranial pressure from the hydrocephalus and/or the small posterior fossa volume in these patients. Drainage of associated hydrocephalus may be an effective surgical treatment.