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There is growing evidence to support the use of motor cortex stimulation (MCS) in the management of patients with chronic neuropathic pain. A prospective audit of ten patients using a modified staged technique for motor cortex implantation provides further evidence for the analgesic effectiveness of this technique. Ten patients suffering from phantom limb pain (n=3), post stroke pain (n=5), post traumatic neuralgia secondary to gunshot injury to the brain stem (n=1) and brachyalgia secondary to neuro-fibromatosis (n=150% pain relief) and long-term benefit in 4/5 of patients who initially responded to intermittent cortical stimulation (longest follow up 31 months after implantation). Of those patients who benefited two had post stroke pain, two phantom limb pain and one post-traumatic neuralgia. We conclude that motor cortex stimulation is an effective analgesic intervention in some patients with chronic neuropathic pain, but it is difficult if not impossible to predict those patients who may respond to treatment prior to implantation. Randomised controlled trials are now urgently needed to test the effectiveness of motor cortex stimulation under double-blind conditions.

A rare case is described of acute disseminated intravascular coagulation (DIC) following isolated mild head injury with acute subdural haematoma, coagulopathy onset preceding craniotomy. Surgical treatment of the cause followed by swift diagnosis and treatment soon after surgery enabled a good outcome. Post-operative recollection of subdural and extadural blood was treated by further surgery. DIC following isolated mild head injury without axonal damage is rare, but fatal if missed. Thrombocytopaenia in head injured patients should be investigated expediently. Post-operative interim imaging (if not standard practice) should also be considered to exclude haemorrhagic recollection requiring further surgery.

Percutaneous dilatational tracheostomy (PDT) is associated with a number of life-threatening complications. We present a case of massive and fatal arterial haemorrhage that occurred in the intensive care unit during an elective PDT on an 86-year-old woman following earlier evacuation of a traumatic subdural haematoma. An avulsed right subclavian artery was found at post mortem. Previous thyroid surgery and aberrant arterial anatomy contributed to the fatal outcome. Br J Anaesth 2003; 90: 517–20

Deep brain stimulation (DBS) is an expanding field within neurosurgery. With many neurosurgeons performing relatively small numbers of these procedures, detailed descriptions of the technical aspects and nuances of DBS may be worthwhile. We describe our technique for DBS, based on over 300 procedures. This methodology continues to evolve and is refined according to our own experience, our observations of others, technological innovations, and information derived from the neurosurgical literature. The indications for DBS in our service are outlined, the anatomical targets described, and the anaesthetic and surgical aspects detailed.