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Recognizing depression in Parkinson's disease can be problematic but since it has such a significant impact on the quality of life in these patients and is easily treatable the value of therapeutic intervention should not be underestimated.

Objective: To compare the ease of use of atraumatic needles with standard needles for diagnostic lumbar puncture and the incidence of headache after their use. Design: Double blind, randomised controlled trial. Setting: Investigation ward of a neurology unit in a university hospital. Participants: 116 patients requiring elective diagnostic lumbar puncture. Interventions: Standardised protocol for lumbar puncture with 20 gauge atraumatic or standard needles. Outcome measures: The primary end point was intention to treat analysis of incidence of moderate to severe headache, assessed at one week by telephone interview. Secondary end points were incidence of headache at one week analysed by needle type, ease of use by operator according to a visual analogue scale, incidence of backache, and failure rate of puncture. Results: Valid outcome data were available for 97 of 101 patients randomised. Baseline characteristics were matched except for higher body mass index in the standard needle group. By an intention to treat analysis the absolute risk of moderate to severe headache with atraumatic needles was reduced by 26% (95% confidence interval 6% to 45%) compared with standard needles, but there was a non-significantly greater absolute risk of multiple attempts at lumbar puncture (14%, −4% to 32%). Higher body mass index was associated with an increased failure rate with atraumatic needles, but the reduced incidence of headache was maintained. The need for medical interventions was reduced by 20% (1% to 40%). Conclusions: Atraumatic needles significantly reduced the incidence of moderate to severe headache and the need for medical interventions after diagnostic lumbar punctures, but they were associated with a higher failure rate than standard needles.

We have analysed video recordings of 21 patients with cervical dystonia treated with botulinum toxin. Fourteen patients have a record both of their response shortly after injections were commenced and between four years five months and six years seven months later. Our analysis shows that the long term outcome is often better than the initial response. We suggest that chronic treatment with botulinum toxin allows different muscles to those initially injected to be identified as contributors to the dystonia. Subsequent injection of these muscles leads to further improvement. It implies that cervical dystonia is a more widespread disorder of motor control, rather than simply limited to a few muscles.

The development and utilization of a tissue culture system for the analysis of quiescent, nonreplicating herpes simplex virus type 1 (HSV-1) genomes is described. It was demonstrated previously that the HSV-1 Vmw65 mutant in1814, which is impaired for immediate early (IE) transcription, was retained for many days in human fetal lung (HFL) fibroblasts in a quiescent 'latent' state. Molecular analysis of the viral genome was not possible, however, due to residual expression of IE proteins and consequent cytotoxicity at high m.o.i. In the study reported here, IE transcription was reduced further by pretreatment of cells with interferon-alpha (IFN-alpha) and by the use of mutant in1820, a derivative of in1814 in which the Vmw110 promoter was replaced by the Moloney murine leukaemia virus (Momulv) enhancer. The Momulv enhancer was not expressed under IE conditions; thus in1820 was more impaired for replication than in1814 and behaved as if deficient for both Vmw65 and Vmw110. In cells pretreated with IFN-alpha and subsequently infected with in1820 cytotoxicity was overcome, enabling a tissue culture system to be developed in which all cells stably retained at least one quiescent viral genome. To assist the analysis of gene expression, in1820 was further modified by insertion of the Escherichia coli lacZ gene controlled by the human cytomegalovirus enhancer (mutant in1883) or the HSV-1 immediate early Vmw110 promoter (in1884). Expression of beta-galactosidase was not detected after infection of IFN-alpha-pretreated cells with in1883 or in1884 but could be induced in almost all cells containing a viral genome, by superinfection of cultures. In1820-derived viruses were retained for at least 9 days and were not reactivated by subculture of cells. A regular arrangement of nucleosomes, as found in cellular chromatin, was not detected on the viral genome at the thymidine kinase locus. The non-linear genome was a template for reactivation with no requirement for prior conversion to a linear form. A small number of remaining linear genomes resulted from incomplete uncoating of input virus.

The aetiology of headache after lumbar puncture is related to the hole left in the dura after the needle has been withdrawn, which allows the cerebrospinal fluid to leak out of the subarachnoid space. The headache can persist for prolonged periods and predispose to subdural haematomas, which are associated with a high mortality. Tourtellotte showed that this headache could be significantly reduced by using smaller needles.1 Also, among needles of the same size, those with atraumatic blunt tips are associated with a lower incidence of headache. They produce a smaller hole in the dura by separating rather than cutting the elastic fibres, as occurs with the Quincke tipped needles.2 We carried out a questionnaire survey of departments of neurology and neurosurgery to see if these needles were used in the practice of diagnostic lumbar puncture and to assess how else departments may be trying to prevent …

Two cases of hypercholesterolaemic patients are presented in whom raised plasma creatine kinase was noted during treatment with statins. The plasma creatine kinase failed to fall following cessation of therapy. Further investigation revealed the aetiology of the raised plasma creatine kinase to be due to previously undiagnosed glycogen storage diseases (McArdle's and Pompe's diseases).

Acute spinal cord compression is an emergency where irreversible neurological damage can occur within hours. The diagnosis should be considered in any patient with an acute paraparesis, parasthesiae, or urinary retention, but there is commonly a delay because neurological examination is incompletely performed or the urgency of the condition is not appreciated. In the days of myelography the whole spinal axis up to the foramen magnum was routinely examined, but nowadays the use of more sophisticated imaging may miss the lesion because of the tendency to restrict the imaged field to the likely clinical site. If the signs are falsely localising there is a danger of missing a treatable cause. We describe a case where the sensory level localised the lesion 11 cord segments distal to the abnormality, leading to a serious delay in diagnosis. Normal radiological examination at the clinical site of a cord lesion should prompt investigation at higher levels ### Case report A 68 year old right handed retired joiner was admitted with acute retention of urine. There had been no prostatic symptoms and no constipation. Three weeks earlier he had developed numbness on the anterior aspects of his thighs. In the initial examination he was reported to have Medical Research Council grade 4 power globally in the legs with normal tendon reflexes and plantar responses. There was impairment of pinprick sensation bilaterally below the inguinal ligament with sacral sparing. Rectal examination and chest x ray examination were normal. Two days later he was unable to stand and he was transferred as a neurosurgical emergency with a provisional diagnosis of an …

Editor—Serpell et al’s survey of lumbar puncture practice in the United Kingdom reminds us that small (22-26 gauge), atraumatic needles, which reduce the incidence of headache after lumbar puncture, are not being routinely used.1 The incidence of headache after lumbar puncture is roughly 35% with 20 gauge standard needles, 5% with 22 gauge atraumatic needles, and 1% with 25 gauge atraumatic needles.2 Adequate cerebrospinal fluid can be obtained by aspirating with smaller needles. The cost of an atraumatic (Whitacre or Sprotte) needle is about £4, compared with £1 for the standard (Quincke) needle. Using 22 gauge atraumatic needles would therefore cost £10 per headache prevented. A third of headaches after lumbar puncture are described as severe, prolonged, or debilitating and unresponsive to simple measures.3 Prolonged headache after lumbar puncture can lead to subdural haematoma.4 The authors mention that epidural blood patching is a successful way of treating persistent headache after lumbar puncture. Epidural blood patching is widely used by anaesthetists for the more severe headache after lumbar puncture caused accidentally by large 16 gauge or 18 gauge epidural needles.5 I conducted an audit at a district general hospital that performs about 150 lumbar punctures annually. Only three out of 26 doctors were aware of the option of epidural blood patching for headache after lumbar puncture (eight junior house officers, 10 middle grade doctors, and eight consultant or staff grade doctors were surveyed). In addition, less than half (of all grades) were able to state correctly the characteristic features of headache after lumbar puncture—fronto-occipital distribution, relief when the patient lies down, onset up to several days after dural puncture, and duration up to several weeks. Clearly, these points still need to be disseminated to all those who perform and teach how to perform lumbar puncture. This is an important message that is equally relevant to surgeons, obstetricians, and general practitioners who encounter headache after lumbar puncture or spinal or epidural anaesthesia.