Karin Leder, Leisa Weld, David O. Freedman, Jim Black, and Joseph Torresi Victorian Infectious Diseases Service Centre for Clinical Research Excellence, Royal Melbourne Hospital, University of Melbourne and Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia; Centers for Disease Control and Prevention, Atlanta, Georgia; and Division of Geographic Medicine, University of Alabama at Birmingham

BACKGROUNDA consensus conference recommended empirical antibiotic therapy for all patients with postoperative meningitis and treatment withdrawal after 48 or 72 h if cerebrospinal fluid culture results are negative. However, this approach is not universally accepted and has not been assessed in clinical trials.METHODSWe performed a cohort study of all patients who received a diagnosis of postoperative meningitis from January 1998 through May 2005 in a teaching hospital. From January 1998 through September 2003 (control period), guidelines were lacking or were not implemented. From October 2003 through May 2005 (interventional period), all patients received a predefined intravenous antibiotic therapy that was discontinued on the third day if the meningitis was considered aseptic. Clinical outcome and duration of antibiotic therapy were analyzed for each patient.RESULTSSeventy-five episodes of postoperative meningitis (21 cases of bacterial meningitis and 54 cases of aseptic meningitis) were investigated. Patients with aseptic meningitis received antibiotic treatment for a mean +/- standard deviation duration of 11+/-5 days during the control period and 3.5+/-2 days during the intervention period (P=.001). The duration of antibiotic treatment for bacterial meningitis was not significantly different between the 2 periods. All episodes of bacterial and aseptic meningitis were cured, and complications were rare during both periods.CONCLUSIONSStopping antibiotic treatment after 3 days is effective and safe for patients with postoperative meningitis whose cerebrospinal fluid culture results are negative.

INTRODUCTION:Ossification of the posterior longitudinal ligament of the spine is a rare cause medullar compression. OBSERVATION:A 50-year-old man from Senegal was referred with recent-onset mechanical lumbar pain with proximal motor deficiency of the lower limbs and somatosensory disorders. Magnetic resonance imaging revealed layered medullar compression, due to anterior cervical and mixed anterior and posterior thoracic ossification. Corticosteroid treatment led to regression of the pain and neurological disorders within a few days. DISCUSSION:This case report of ossification of the posterior longitudinal ligament of the spine appears to be an idiopathic form corresponding to the "Japanese disease" initially thought to be limited to that population.

To the Editor: We managed a case of suspected spinal hematoma (SH) after a failed attempt of epidural analgesia during labor. A 32-year old multiparous woman was admitted at 38 weeks’ gestation for left iliac vein thrombosis and was treated with Enoxaparin 70 mg twice daily that was switched to continuous IV un-fractionated heparin 5 days later (activated partial thromboplastin time [aPTT]: 54 s [normal value < 40 s]). At the end of the 39th week, heparin was discontinued and labor was induced with oxytocin. Four hours after heparin discontinuation, aPTT was 31 s. After informed consent and at the patient request, epidural placement was attempted at the L3–4 interspace in the sitting position, 6 hours after heparin discontinuation. Direction of the needle was changed four times before epidural space could be located. A multihole flexible epidural catheter (18-gauge, no inside leader, Portex Ltd, Keene, U.S.) was introduced 4 cm cephalad in the epidural space. A frank blood tap was immediately observed in the catheter, which prompted both catheter and needle removal. The patient wished to rest for a moment, and no further attempt of epidural analgesia was done. One hour later, she complained for severe back pain located at the L3–4 interspace with bilateral and cephalic radiation, suggesting radicular back pain. Pain was constant, not altered by uterine contraction and clearly differentiated by the patient from uterine contraction. Pain was unchanged by vertebral palpation and no sensory or motor deficit was observed. No symptom of subarachnoid hemorrhage was found. Epidural hematoma was suspected. After a neurosurgeon’s advice was obtained, it was decided, in order to reduce the delay before spinal imaging and eventually surgery, to perform emergent C-section under general anesthesia after patient information and consent. Magnetic resonance imaging (MRI), done 4 h after back pain onset, ruled out SH. Backache decreased progressively and disappeared in 6 h. Neurological examination remained normal. Enoxaparin (70 mg twice daily) was reintroduced 18 h after the failed epidural. Postpartum period was uneventful with normal neurological status. Confirmation of SH by specific imaging is an emergency, since neurological prognosis of SH depends on the delay between SH symptoms and decompressive laminectomy (1–3). Classical features of SH (i.e., backache, cauda equina syndrome) can be masked by neuraxial block and diagnosis is commonly suspected in face of unusual recovery from neuroaxial block. In our case, we had to manage a suspected SH very early during labor as epidural analgesia was abandoned. The benefit/risk ratio of three strategies were analyzed. Immediate MRI was considered, but was found not possible because of the problem to obtain several minutes of stillness in a laboring woman without analgesia. To expedite vaginal delivery and perform MRI just after was not considered appropriate, as the duration of labor is unpredictable, leading to an unacceptable delay in SH diagnosis. Furthermore, SH extension may be favored by both uterine contractions and pushing efforts that lead to epidural venous plexus congestion. The strategy we choose gives the advantage to reduce the delay before MRI to 4 h, and to limit the duration of uterine contractions and avoid pushing efforts, but was balanced with a fivefold increase in the perioperative risk of C-section under general anesthesia as compared with vaginal delivery (4). This case emphasizes the difficulty to analyze back pain during labor and the problem of early SH diagnosis on clinical symptoms only. Beny Charbit, MD Emmanuel Samain, MD, PhD Pierre Albaladejo, MD, PhD Younes El Houari, MD Frédérique Le Corre, MD Aimée Redondo, MD, PhD Bruno Deval, MD Jean Marty, MD, PhD Department of Anesthesia and Intensive Care Department of Obstetric and Gynecology Department of Anesthesia and Intensive Care Department of Neurosurgery Department of Obstetrics and Gynecology Department of Anesthesia and Intensive Care, Hôpital Beaujon, University Xavier Bichat, Clichy, France

A case report of an adult patient with an osteoid osteoma of the lamina of 9th thoracic vertebra is presented. The long history of progressively worsening nocturnal dorsal pain which was relieved by non-steroid anti-inflammatory drugs, and an essentially clinical examination, are typical of this condition in which the CT and radionuclide bone scans are the investigation of choice. Complete relief was obtained following excision of the lesion. The literature is reviewed.

The purpose of this article is to clarify interactions between oral contraception (using low- and high-dose oral contraceptives) and the main neurological diseases occurring in genitally active women. Vascular disorders predominate, since contraception is in itself a well-recognized a risk factor, especially in case of other intercurrent risk factors (high blood pressure, smoking, diabetes, history of vascular event) contradicting contraception. Low-dose oral contraception can be proposed for women free of these risk factors. There is however a formal contraindication for oral contraception, even with mini-dose contraceptives, for women with a history of cerebral venous thrombosis. In case of migraine headache, which is also a risk factor of vascular disease (especially in case of aura), oral contraceptives should be discussed on an individual basis, depending on the presence of other risk factors. Contraception has no effect on epilepsy but oral contraceptives may be inhibited by inducing anti-seizure drugs. Non-inducing drugs are preferable. The course of certain brain tumors known to express estrogen or progesterone receptors (particularly meningiomas and hemangioblastomas) may worsen with oral contraception, which is formally contradicted except when search for hormone receptors is negative. Oral contraception has no influence in other disease such as multiple sclerosis.

Whipple's disease is a rare infectious disease with potential central nervous system manifestations and a poor prognosis. We report the case of a young woman who presented with acute intracranial hypertension associated with cholestasis which revealed Whipple's disease without digestive involvement. The diagnosis was supported by the presence of PAS-diastase positive hepatic granulomas. A long course of antibiotics resulted in complete remission of the disease without relapse. An acute neurologic syndrome associated with cholestasis should suggest Whipple's disease.