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The analgesic effectiveness and adverse effect incidence of a daily dose of 10 or 20 mg of oral methadone were evaluated in 18 patients with a diverse range of chronic neuropathic pain syndromes, who had all responded poorly to traditional analgesic regimens. Analgesia was seen after each dose of methadone. As compared with placebo, the 20 mg daily dose (given as 10 mg bd) resulted in statistically significant (P = 0.013-0.020) improvements in patient Visual Analogue Scale ratings of maximum pain intensity, average pain intensity and pain relief, recorded at the same time daily. The analgesic effects extended over 48 hours, as shown by statistically significant (P = 0.013-0.020) improvements in all three outcomes on the rest days instituted between each daily dose. Analgesic effects (lowered maximum pain intensity and increased pain relief, on the day of dosing only) were also seen when the lower daily dose of 10 mg methadone (given as 5 mg bd) was used, but these failed to reach statistical significance (P = 0.064 and 0.065, respectively). Interpatient analysis showed that the analgesic effects were not restricted to any particular type of neuropathic pain. Patient compliance was high throughout the trial. One patient withdrew during the 10 mg and six during the 20 mg methadone treatment periods. This is the first double-blind randomized controlled trial to demonstrate that methadone has an analgesic effect in neuropathic pain. [ABSTRACT FROM AUTHOR]

Over the last few years, a number of works have been published asserting both the putative prosocial benefits of belief in free will and the possible dangers of disclosing doubts about the existence of free will. Although concerns have been raised over the disservice of keeping such doubts from the public, this does not highlight the full danger that is presented by social psychology's newly found interest in the 'hard problem' of human free will. Almost all of the work on free will published to date by social psychologists appears methodologically flawed, misrepresents the state of academic knowledge, and risks linking social psychology with the irrational., (© 2011 The British Psychological Society.)

The observation that while Roy Baumeister does not accept that there is a strong link between belief in free choice and malign effects on the weak and unlucky, the Baumeister and Vonasch study newly evidences discrimination against the poor and unlucky through belief in free choice. Baumeister also acknowledges that institutional-level injustice is exacerbated by belief in free will. Bargh seems to acknowledge Baumeister's inconsistency, but introduces a different fallacy when he suggests the debate is not really about freedom of choice. Miles argues that even for a self-styled 'compatibilist' like John Bargh, this debate is all about free choice., (© 2013 The British Psychological Society.)

Spinal cord stimulation (SCS) is a treatment modality for medically intractable chronic pain. This study reports an 11-year experience with SCS assessing long-term pain relief and specifically evaluating complications and revisions. It took the form of a retrospective review of medical/surgical records with a postal questionnaire. The subjects were 102 patients with medically intractable chronic pain who underwent SCS implantation between 1989 and 2000. There were 64 revision operations carried out on 35 patients. These comprised electrode replacement/repositioning (29), generator replacement (23), cable failure (3) and implant removal (5). Five (4.9%) implants became infected and 2 required removal. Clinician-reported pain relief was substantial in 69 (68%) patients. This study adds to the weight of evidence that patients undergoing SCS derive significant benefits in terms of pain relief. However, revision rates remain high due to technical and biological factors., (Copyright 2003 S. Karger AG, Basel)

Oxidised regenerated cellulose (Surgicel) is a commonly used haemostatic agent in neurosurgery, thoracic surgery, and orthopaedics. We present three cases of paraplegia after thoracic surgery during which oxidised cellulose had been used during thoracotomy for haemorrhage control, and was later found to have passed through the intervertebral foramen causing spinal cord compression. In all intraspinal and perispinal procedures, the over-liberal use of Surgicel should be avoided, and attempts made to remove all excess Surgicel once adequate haemostasis is obtained.

An unusual case of recurrent iliac crest donor site pain secondary to heterotopic bone formation is described. The literature is reviewed with a special emphasis on the aetiology and treatment of this entity.

The authors report on three patients suffering from coexistent trigeminal neuralgia (TGN) and Charcot-Marie-Tooth disease who, based on preoperative magnetic resonance tomographic angiography findings, underwent microvascular decompression. All patients had demonstrable neural compression and all experienced immediate postoperative pain relief. Symptoms recurred in one patient and required a second procedure in the form of a neurotomy. Two patients suffered from bilateral TGN. When a patient with TGN suffers coexistent neurological disease and experiences bilateral symptoms, preoperative imaging and subsequent decompressive surgery may avoid the unacceptable risk of morbidity associated with bilateral ablative procedures.

In order to illustrate the inherent problems of managing bilateral trigeminal neuralgia a retrospective study of the 16 cases of bilateral trigeminal neuralgia, out of just over 300 cases of trigeminal neuralgia, treated over a 14-year period, has been performed. All the patients, presented with a typical history of trigeminal neuralgia and underwent surgical exploration. Pain relief was initially achieved in all cases; however, only four remained cured, three have become pain free after additional rhizotomy, a further one after peripheral cryotherapy and four with medical treatment. Four patients have had bilateral operations for trigeminal neuralgia, but in two cases the pain was relieved on one side only. Bilateral trigeminal neuralgia presents special problems of management with respect to underlying neuropathology (e.g. multiple sclerosis), the need for the limitation of the use of ablative techniques in order to minimise the disability of bilateral sensory and motor dysfunction, and the relatively poor response to microvascular decompression. These factors emphasize the multifactorial nature of the cause of trigeminal neuralgia. Magnetic resonance tomographic angiography is now available and is important in determining the range of therapeutic options for this group of patients.

Spontaneous subacute and chronic haematoma in young adults is rare. It has not been previously reported in this age group. We present three cases of chronic and subacute subdural haematoma in young adults, in one of whom the diagnosis was certainly delayed. All three patients underwent burrhole evacuation and made a full neurological recovery. A cause for the haematoma was never established. The literature on the subject, which is scanty, is reviewed and the condition is briefly discussed. The aetiology remains obscure.

A retrospective analysis of long-term efficacy of percutaneous radiofrequency thermocoagulation of the trigeminal ganglion or root for the relief of trigeminal neuralgia was carried out in our unit. From the medical records and questionnaires, outcomes of 108 procedures performed in 81 patients from January 1986 to December 1990 were obtained with a follow-up period of 6-11 years. The initial success rate was 87% and the probability of remaining pain-free 1, 2 and 11 years after the procedure was 65, 49 and 26%, respectively. Patients with typical symptoms had a better long-term efficacy than those with atypical presentations, and patients who had not undergone a previous surgical procedure also had a better outcome. There was no mortality in this series. Common adverse effects included dysaesthesia in 20 patients, corneal numbness in 12 patients and masseter weakness in three patients.

Percutaneous spinal cord stimulation (SCS) (Medtronic model 3487A PISCES-Quad lead) was carried out in 10 patients with rest pain from advanced peripheral vascular disease of the lower limb, who were unsuitable for conventional treatment. Trial stimulation ranged from 1-20 weeks and was associated with pain relief in nine of the patients. Claudication distance was improved in six patients. Trophic lesions improved in one patient with small artery disease. Spinal cord stimulation did not reverse the course of acute gangrenous lesions. The distal arterial pressure measured by Doppler Ankle/Brachial Pressure Index, (ABPI), showed no change. The capillary blood flow and skin temperature of both feet, measured, respectively, by Laser Doppler flowmetry and skin thermistor, showed a tendency to decrease when the stimulation was at the higher level, above T10, compared with an increase when the stimulation was at the lower level T12. Transcutaneous oxygen tension monitoring of the symptomatic foot showed an increase in four out of five patients. Pain relief was not dependent on circulatory changes, but it was more significant when the circulatory changes showed an impressive increase in the blood flow. The mechanism of these circulatory changes is probably by modulation of the sympathetic nervous system. Recognition of the optimal sitting of SCS may be critical in the clinical use of this technique, which seems to be a valuable option in the treatment of patients with advanced peripheral vascular disease (PVD).

Human MPF (Lys-Lys-Gly-Glu) stimulates the proliferative response of human lymphocytes to the T-cell mitogen concanavalin A by 121-751% in the concentration range 10(-11)-10(-4) M; the peak effect is at 10(-8) M, lower or higher concentrations eliciting reduced responses, i.e. the dose-response curve is bell-shaped. Species specificity is high. Human MPF similarly stimulates rat lymphocytes, but the peak effect is seen at a 100-fold higher dose (10(-6) M). Rat MPF (Lys-Lys-Gly-Gln) has a peak effect at 10(-6) M with human lymphocytes, but the peak effect with rat lymphocytes is at a 1000-fold lower dose (10(-9) M). Truncated forms of the MPFs (Gly-Glu, Gly-Gln, Gly, Glu, Gln) and opioid peptides (beta-endorphin, [Leu] and [Met]enkephalin) show insignificant or only weak stimulatory or inhibitory effects. These results suggest that MPF acts via specific non-opioid receptors located on lymphocytes and that endogenously released MPF may have an important role in the functioning of the immune system.

Pain in the face following microvascular decompression (MVD) can be due to persisting trigeminal neuralgia (TGN) or a variety of other facial pain syndromes. If magnetic resonance tomoangiography (MRTA) indicates continuing vascular compression and the patient has true persistent TGN, then the patient can be relieved of pain by repeating the MVD. When the MRTA is negative for continuing compression alternative techniques may be employed; section of the nerve at the pons may be the treatment of choice for true persistent TGN in the absence of neurovascular compression. In some cases the pain is dysaesthetic in nature and not persistent TGN. This is always associated with previous destructive lesions to the nerve, usually radio-frequency thermocoagulation. When this component to the pain is recognized pre-operatively the patient must be warned not to expect relief of this same component of the pain from MVD. When it is not possible to classify the facial pain clinically, improvement does not occur following MVD even when there is clear evidence of vascular compression on MRTA.

Syringomyelia is the condition in which longitudinal cavities are found within the spinal cord. The use of drainage procedures has been widely practised with good short term results. However, the long-term results in some large series have been less favourable. There are many associated conditions and in most forms a blockage to the normal flow of CSF, either at the foramen magnum or in the spinal canal, can be identified. Most surgeons would now direct their efforts to the establishment of normal CSF flow rather than a shunting procedure. In a certain group of patients, even with the advent of sophisticated MRI, no associated abnormality or CSF block is easily identified. This type of syringomyelia is often termed idiopathic. We report 10 patients with symptomatic syringomyelia without readily recognized predisposing factors. In eight patients preoperative myelography revealed a block to the flow of contrast compatible with subarachnoid obstruction. Eight patients underwent laminectomy and division of the obstructing arachnoid webs. Five experienced good improvement and three only moderate improvement. Two of the patients underwent syrinx shunting procedures only, which resulted in a worsening of their symptoms. At operation one patient was found to have an arachnoid cyst. We believe that patients with idiopathic symptomatic syringomyelia may need myelography to identify such arachnoid abnormalities. Subsequent surgery should be directed at the establishment of normal CSF flow by laminectomy and excision of the offending lesion.

The authors investigated 28 patients with "idiopathic" trigeminal neuralgia who had undergone no previous invasive procedures; together these patients had a total of 50 affected trigeminal divisions. Quantitative sensory perception thresholds were measured before operation. Preoperative measurements in the affected divisions indicated raised thresholds for touch (von Frey filaments) and temperature, but not for pinprick or heat pain, in agreement with the findings of Nurmikko. Only the tactile threshold was also significantly affected in the unaffected divisions on the affected side. The authors discuss their findings in relation to the pathophysiology of trigeminal neuralgia, concluding that the origin of the condition is almost certainly central to the gasserian ganglion.

Nineteen patients with "idiopathic" trigeminal neuralgia, who had not undergone any previous interventional procedures, possessed a vessel or vessels compressing the preganglionic nerve root that was demonstrated by magnetic resonance tomographic angiography. Pain was relieved immediately in all of these patients after they underwent microvascular decompression without observed nerve damage. Although preoperative measurement of sensory perception thresholds showed elevations in the thresholds for touch (von Frey filaments) and warmth and coolness sensations, these thresholds normalized during the postoperative period. An apparent deficit in the pinprick (sharpness) sensation appeared postoperatively, but the deficit gradually regressed and completely disappeared by 1 year after surgery; this phenomenon may have been a statistical anomaly. The patients' pain disappeared immediately postoperatively and remained absent throughout the follow-up period. The authors conclude that damage to the nerve or nerve root is not essential for the relief of trigeminal neuralgia.

MPF is a tetrapeptide (structure Lys-Lys-Gly-Glu) that elicits a variety of neurotrophic effects in vivo consistent with a role in neuronal regeneration. In support of this role, we now show that MPF stimulates the proliferation of cultured astrocytes and neurite outgrowth from cultures of neocortical cholinergic and mesenchephalic dopaminergic neurons. The dose-response relationships are biphasic ("bell shaped"), maximal responses being obtained with 10(-6) M concentrations of MPF. MPF and nerve growth factor seem to act on different receptors, because their effects on cholinergic neurons are synergistic.

We describe a case of dumbbell hydatid cyst of the T(10) pedicle. This cyst had both extradural and retroperitoneal components,leading to spinal cord compression and abdominal pain. Following surgical excision and irrigation with hypertonic saline the patient made a full recovery, and is recurrence-free after 18 months follow-up.

A 71-year-old male with multiple sclerosis and trigeminal neuralgia due to vascular compression underwent multiple radio-frequency nerve lesioning bilaterally. He was anaesthetic on the left side and required right microvascular decompression. He died after this procedure. The pathology of the pons and the effects of treatment are described.

Until recently, the inability to demonstrate neurovascular compression of the trigeminal nerve preoperatively resulted in surgery being offered only in cases of severe trigeminal neuralgia (TGN), frequently after a prolonged trial of medical treatment and following less invasive procedures, despite the fact that posterior fossa microvascular decompression gives long-term pain relief in 80% to 90% of cases. To assess whether vascular compression of the nerve could be demonstrated preoperatively, high definition magnetic resonance tomographic angiography (MRTA) was performed in 50 consecutive patients, five of whom had bilateral TGN, prior to posterior fossa surgery. The imaging results were compared with the operative findings in all patients, including two patients who underwent bilateral exploration. Vascular compression of the trigeminal nerve was identified in 42 of 45 patients with unilateral symptoms and on both sides in four patients with bilateral TGN. In the last patient with bilateral TGN, neurovascular compression was identified on one side, and on the other side the compressing superior cerebellar artery was separated from the nerve by a sponge placed during previous surgery. There was full agreement regarding the presence or absence of neurovascular compression demonstrated by MRTA in 50 of 52 explorations, but MRTA misclassified four vessels compressing the trigeminal nerve as arteries rather than veins. In two cases, there was disagreement between the surgical and MRTA findings. In the first of these cases, surgery revealed distortion of the nerve at the pons by a vein that MRTA had predicted to lie 6 mm remote from this point. In the second patient, venous compression was missed; however, this patient was investigated early in the series and did not have gadolinium-enhanced imaging. In nine cases, MRTA correctly identified neurovascular compression of the trigeminal nerve by two arteries. Moreover, MRTA successfully guided surgical reexploration in one patient in whom a compressing vessel was missed during earlier surgery and also prompted exploration of the posterior fossa in two patients with multiple sclerosis and one patient with Charcot-Marie-Tooth syndrome, in whom neurovascular compression was identified preoperatively. It is concluded that MRTA is an extremely sensitive and specific method for demonstrating vascular compression in TGN. As a result, open surgical procedures can be recommended with confidence, and microvascular decompression is now the treatment of choice for TGN at the authors' unit. They propose MRTA as the definitive investigation in such patients in whom surgery is contemplated.

Seven consecutive patients with multiple sclerosis and trigeminal neuralgia were investigated with MRI to determine the occurrence of a lesion which would account for the patients' pain. Two patients had bilateral symptoms. In the patients with unilateral trigeminal neuralgia vascular compression of the nerve by an artery at the root entry zone on the symptomatic side was confirmed in three patients and an epidermoid tumour distorting the nerve on the symptomatic side was identified in one patient. A demyelinating plaque was identified in only one patient, affecting the trigeminal nerve at the root entry zone at the pons. In those with bilateral symptoms neurovascular compression was identified on both sides in one patient and on one side only in the remaining patient. Microvascular decompression cured the pain in two patients with neurovascular compression. The variable aetiology of trigeminal neuralgia is stressed even in patients with coexistent neurological conditions such as multiple sclerosis, which can cause trigeminal neuralgia independent of other causes.

Hemispherectomy is well recognized as an effective treatment for some types of intractable epilepsy, but the procedure is also known to be associated with significant late complications. A number of modifications to the original operation have been developed to try and minimize such late complications. These are reviewed and a further modification is described using a Zenoderm graft to isolate the hemispherectomy cavity from the remaining CSF pathways. We present our early experience with this new modification in seven patients with intractable epilepsy.

Objective: Vascular contact with the trigeminal nerve at the pons is known to cause trigeminal neuralgia; however, this finding also is present in some asymptomatic subjects. We evaluated the usefulness of high-resolution MR imaging and MR angiography of the posterior fossa to determine the presence or absence of vascular contact with the fifth cranial nerve at the pons in patients with trigeminal neuralgia and in control subjects., Subjects and Methods: The trigeminal nerves in 40 symptomatic patients and 114 asymptomatic control subjects were examined for the presence or absence of vascular contact at the pons by using three dimension (3D) fast inflow with steady-state precession (FISP) imaging. Imaging parameters were 35/7/15 degrees (TR/TE/flip angle) with a slab thickness of 55 mm and 64 partitions. Contrast-enhanced imaging was done in 10 of 12 patients with normal findings on an unenhanced scan. Axial, coronal, sagittal, and maximum-intensity-projection images were reviewed by two observers who had no knowledge of the clinical details. The findings on MR images were prospectively compared with the surgical findings in 25 patients., Results: On the unenhanced MR images, vascular contact with the trigeminal nerve at the pons was identified in 70% of 40 nerves in patients with trigeminal neuralgia and in a further 15% following injection of contrast medium. Contact between the nerve and two vessels at the pons was seen in 10% of cases, and deformity of the nerve was present in 30% of cases. In the control group, vascular contact with the nerve was identified in 8% of 114 nerves. Contact between the nerve and two vessels or deformity of the nerve was not identified in any control subject. The difference between the two groups was highly significant regarding the presence or absence of vascular contact with the nerve at the pons (p < 0.001, x2 test), distortion of the nerve (p < .001), and contact between the nerve and two vessels (p < .001). The imaging findings were in agreement with the surgical findings regarding the presence or absence of vascular contact with the nerve in all 25 patients who had surgery. Complete or partial pain relief was achieved following microvascular decompression in all patients who had surgery., Conclusion: Despite the fact that vascular contact with the trigeminal nerve at the pons is not specific for trigeminal neuralgia, high-definition unenhanced and enhanced 3D FISP imaging and MR angiography at the posterior fossa are useful in determining the presence or absence of vascular contact with or deformity of, the fifth cranial nerve in patients for whom surgery is planned for treatment of trigeminal neuralgia.

We have previously shown that a metabolically stable analogue of MPF, the C-terminal tetrapeptide of human beta-endorphin of structure Lys-Lys-Gly-Glu, reduces the turning behaviour of rats with unilateral lesions of their nigro-striatal pathways. Transmission electron microscopy (TEM) has now revealed that this effect is related to reversal of the mitochondrial damage to substantia nigra (SN) neurones induced by the lesion. The results are consistent with the concept that an inherited defect in components of the mitochondrial enzyme system is the initial step in the genesis of Parkinson's disease (PD). They also, in conjunction with known neurotropic properties of MPF, and our unpublished finding of high concentrations of an MPF-like peptide in human basal ganglia, suggest that MPF may have physiological significance in the development and regeneration of the human CNS.

The case is reported of a 60-year-old woman with left-sided trigeminal neuralgia, hemifacial spasm, and hypertension. Compression of the left trigeminal, facial, and vagus nerves by the anterior and posterior inferior cerebellar arteries and a persistent trigeminal artery variant were demonstrated by magnetic resonance angiography using a novel sequence. At operation the angiographic appearances were confirmed, and decompression was performed with the placement of polyvinyl sponge at all three levels. Postoperatively, the patient had complete relief from the trigeminal neuralgia and hemifacial spasm and has sustained normotension without medication.

Using postoperative magnetic resonance imaging the accuracy of CT-guided three-dimensional targeting of stereotactic thalamotomy for movement disorders was demonstrated in 13 patients. CT guidance should be adopted for functional neurosurgery in preference to ventriculographic guidance as it can be shown to be sufficiently accurate and it is far less disturbing to the patient.

A single intrastriatal injection of a slow release formulation of a metabolically-stable MPF analogue was given to rats with lesioned right nigrostriatal pathways. After 6 weeks the turning behaviour of the rats in response to D-amphetamine began to decline, and after 12 weeks the reduction was marked and consistent. The implication of our results in the use of intracerebral grafts in parkinsonian patients is discussed.

In this pilot study, to assess the optimal stimulation parameters, 3 different forms of transcutaneous electrical nerve stimulation were performed in 27 patients. Conventional continuous stimulation with a constant frequency of 70 Hz, burst stimulation (90 msec trains of pulses with an internal frequency of 100 Hz repeated at 2 Hz, each train consisting of 10 pulses), and frequency-modulated stimulation (continuous pulses changed from 90 Hz to 55 Hz over 90 msec) were randomly delivered to the patients for half an hour in 3 separate sessions. The patients were blind to the modes of stimulation. This pilot study demonstrated that patients preferred modulated stimulation modes such as frequency modulation and burst rather than conventional constant mode.

Part I of our earlier pilot study demonstrated that patients preferred modulated stimulation forms - frequency modulation and burst - rather than conventional continuous mode. To assess whether long-term therapeutic effects validate the immediate test results, this trial was performed in 14 patients with 21 pain conditions. Considering the results of the pilot study, the test stimulator was modified and 4 different forms of transcutaneous electrical nerve stimulation were randomly delivered to each patient who was blind to the modes of stimulation for 20 min. A second observer assessed the pain scores using visual analogue scales. The stimulation modes employed were: (1) conventional continuous stimulation (continuous pulses with a constant frequency of 70 Hz), (2) burst stimulation (80 msec long trains of pulses, each train consisting of 8 pulses, with an internal frequency of 90 Hz repeated 1.3 times a second), (3) high-rate frequency modulation, HRFM (continuous pulses changed from 90 Hz to 55 Hz over 90 msec, 1.3 times a second), (4) low-rate frequency modulation, LRFM (continuous pulses changed from 60 Hz to 20 Hz over 90 msec, 1.3 times a second). After the test treatment of 4 sessions in the clinic, depending on the pain scores and duration of pain relief recorded, the most effective stimulation mode was determined for each patient and a portable stimulator preset appropriately for that mode was given to be used at home, under our supervision, for 3 months. Fourteen pain conditions out of 21 (66%) responded well to the therapy; the majority preferred was the HRFM and burst-type stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

A rare case of intracranial extension of a naso-ethmoid schwannoma is presented. Its subsequent removal with few sequelae confirmed the benign nature and good prognosis of the disease.

Chronic pain is multi-factorial, and consequently a multidisciplinary approach is essential for its proper management. Pain Clinics may treat acute pain, chronic pain and cancer pain, and need to differentiate between these different conditions. Careful diagnosis and assessment is essential, including history, examination, questionnaires and relevant investigations. A variety of treatments exist to manage chronic pain, some of which have already been discussed in this issue. Treatments may be summarized as drugs, surgical (including nerve blocks), stimulation techniques, psychological techniques and general or physical measures. If a Pain Relief Unit has the ability to provide all of these types of treatment, then it can manage any type of pain, with the ability to relieve pain and improve quality of life greatly in a significant number of sufferers.

Extracranial paranasal spread of meningiomas is uncommon. We describe the management of four cases, all of which first presented to an oto-rhino-laryngologist for an opinion. We suggest that greater use of modern imaging techniques could lead to earlier diagnosis. The natural history of extracranial spread is relatively benign but the management of regrowth of residual disease is difficult. We therefore suggest radical surgery in the first instance provided that the patients general health and configuration of the tumour allow.

Two young women with pituitary gland enlargement and hyperprolactinaemia were referred for pituitary surgery. Both had received bromocriptine (one patient for 13 years) for presumed prolactinoma. Mild clinical signs of hypothyroidism were present and endocrine tests revealed primary autoimmune thyroid failure. Following thyroxine replacement treatment, the pituitary enlargement and hyperprolactinaemia completely resolved. In both patients the hyperprolactinaemia was relatively mild and menorrhagia had been present for many years. A third patient, a 61-year-old man presenting with bitemporal hemianopia due to pituitary enlargement underwent transphenoidal pituitary surgery. The results of thyroid function tests on admission were not available until after surgery. Although the patient was clinically euthyroid, these revealed primary hypothyroidism and his considerable pituitary enlargement may also have been secondary to thyroid failure. Urgent thyroid function tests should be performed in all patients with pituitary enlargement prior to surgery to exclude hypothyroid induced pituitary swelling.

Eleven patients were investigated for pituitary function after the injection of alcohol into the pituitary fossa; all had persistent pain and 8 had carcinoma of the breast. Most of the patients showed varying degrees of reduction of pituitary activity; 8 patients obtained significant pain relief and 3 patients exhibited polyuria. These 3 observations could not be completely correlated; the possible mechanisms which may lead to pain suppression by this method are discussed.

Three cases of extradural spinal lipomas in adults are described in which there was no association with steroids. In all three cases the tumors were situated in the lumbar region and the patients were muscular, nonobese males. Two of the three cases had long histories contrary to those previously reported. Preceding transient neurological symptoms were noted in two of the three cases. The etiology of this phenomenon is discussed. It is possible that these lipomas, which are not associated with steroids, may represent a different spectrum of disease.