We describe a case of a three year old girl with Caudal Regression Syndrome (CRS) at the ninth thoracic vertebral level with termination of the spinal cord at the unusually high level of the third thoracic vertebra. We describe this rare condition and discuss the challenging management in an extremely rare case where there is termination of the spinal cord at a high thoracic level.

CRS is a severe congenital neural and skeletal deficiency that is characterized by absence of the entire sacrum and of variable amounts of the lumbar and occasionally thoracic spine with associated neural elements. This is accompanied by a number of congenital visceral abnormalities.

Controversy belies the optimal orthopaedic management of the spinal anomaly and the associated lower extremity deformities in this condition. Affected children have multiple musculoskeletal abnormalities, including foot deformities, knee and hip flexion contractures, dis-located hips, spino-pelvic instability, and scoliosis.

We believe the care of these complex patients should be highly individualized.

Patients with types I and II lumbosacral agenesis have an excellent chance of becoming community ambulators and early interventions should be taken to correct the associated orthopaedic deformities. Treatment of types III and IV lumbosacral agenesis is controversial. In these severe forms of agenesis periodic examinations of the spine for scoliosis should be performed and the patient must be monitored for spinopelvic instability as indicated by a worsening posture. The management of these and other orthopaedic deformities is controversial but we do advocate the surgical correction of fixed deformities of the lower extremities which interfere with sitting or with the wearing of braces or shoes thereby avoiding amputation and maintaining body image.

The objective of this study was to assess the clinical outcome and efficacy of the X-Stop™ interspinous implant.

67 patients (36 male, 31 female) with mean age of 62.4 years (range 50–94 years) and radiologically proven lumbar stenosis, underwent X-Stop™ implantation during the period of June 2004 to June 2007. Patients were assessed pre-operatively and post-operatively at 3, 6 and 12 months using the Back and Sciatica Questionnaire, the Oswestry Disability and the SF12 questionnaire. Patient’s satisfaction was assessed in each visit. Minimum follow up 2 years in 45 patients and 1 year in 22 patients.

70% had significant improvement in the walking distance following the operation.

With the Back and Sciatica Questionnaire the average preoperative VAS of back and leg pain was 7.1 and 6.7 and improved to 2.5 and 2.6 postoperatively.

86% patient had improvement in their ODI score by 14% and more with average pre and postoperative score 44% (range18%–84%) and 15.8% (range 0%–61%) respectively.

With the SF12 questionnaire 68% patients had significant improvement in physical score and 77% in the mental score. Complications included five superficial wound infections and one wound haematoma. One patient required revision surgery.

This new surgical technique for the treatment of lumbar spinal stenosis, is simple and effective with minimum complications.

We describe the clinical results of a new technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation.

14 patients aged between 10 and 17 years were included in this study. 7 were males and 7 females. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. All patients had undergone at least 12 months of activity modification, a trial of bracing and physical therapy before surgical options were discussed. None of the patients had spondylolisthesis. Definitive pseudo-arthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity. The pars defect was at L5 in all 14 patients.

A midline incision was used for surgery. The pars intercularis defect was exposed and filled with autolo-gous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace.

The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma. Follow-up was at 6 weeks, 6 months and at 1 year. At the latest follow-up, visual analogue scores ranged between 0 and 4 for all patients, indicating excellent overall pain control. Functional assessments for all patients via the modified Oswestry scores were 0% to 13%, indicating a good overall functional result. All patients had radiographs at follow-up which showed fusion rates of 80% in those patients followed up for 1 year.

This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index.

AIM: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty).

METHODS: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation.

We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.

RESULTS & CONCLUSION: There was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation.

Purpose: To compare two different techniques of inter-body fusion in treatment for single level degenerative spondylolisthesis with symptomatic spinal stenosis.

Methods: Retrospective review of patients with degenerative spondylolisthesis and spinal stenosis treated with decompression and instrumented posterior interbody fusion with and without cages. Between 1996 and 2003 there were 59 patients with single level degenerative spondylolisthesis and spinal stenosis. Of these 32 were treated with complete laminectomy, interbody grafting and pedicle screw fixation. In the second group of 27 patients, the technique was modified by the incorporation of an interbody cage in an attempt to improve the restoration of lordosis. Both groups were comparable in terms of pathology, age, sex, intraoperative technique and were treated by the same surgeon. All patients were followed up at 6, 12, 26 and 52 weeks with radiographs and were assessed for fusion and maintenance of lordosis at a minimum of 1 year.

Results: There was a statistically significant difference between pre and postoperative lordotic angles in both groups. There was no significant difference in clinical outcomes between the two groups, nor was there a statistical difference in postoperative lordotic angles at the end of 1 year between the two groups. We had 2 deep infections in the cage group. There was one implant failure in the no cage group.

Conclusion: We did not find any advantage in using interbody cages in treating single level degenerative spondylolisthesis.

Aim: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty).

Methods: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation.

We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.

Results and Conclusion: here was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation.

We present in this study our experience in wide decompression, gradual acute reduction and fusion performed in a single sitting, for high grade spondylolisthesis in 17 adolescent cases.

Between 1994 and 2005 we undertook surgical management of 17 adoloscents with high dysplastic Spondy-lolisthesis. All our patients were young females except for one with average age of 13.9 years. All of our cases involved the lumbosacral junction. 8/14 cases presented with frank spondyloptosis (Grade5). Of the remaining 9 cases, 5/14 cases were grade4 and 4/14 were grade3 dysplastic spondylolisthesis respectively. Our indication for surgery in all these patients was unremitting back pain, radicular pain, abnormal posture, gait abnormalities and progressive slip. All these patients underwent single stage wide decompression, posterior instrumentation and reduction of the slips and postero lateral fusion. Since 1999 in addition to the above we routinely performed inter body fusion with cages in lumbosacral segment (9/17 cases).

All patients’ spondylolistheses were reduced to < grade2.16/17 of our patients had a very satisfactory outcome. Our average follow-up of these patients is 4 years (range 1–9 years).4/17 of our patients developed some dorsiflexion weakness postoperatively and all recovered within 3 months of operation.1 patient developed deep postoperative infection necessitating the removal of the implant.

We conclude that acute correction of high grade spondylolisthesis is a demanding procedure. The newer instrumentation (improved sacral fixation) made reduction less difficult and the final outcome is highly satisfying for the patient and the surgeon.

Introduction and aims: Instrumentation in Spinal Tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem.

Method: We have operated on 147 patients with Spinal Tuberculosis between 1990 and 2001. Between 1990 and 1995 we treated 45 patients in the traditional manner with anterior decompression and strut grafting. During this period we encountered an unacceptably high rate of complications, such as graft collapse, progression of deformity and pseudoarthrosis.

Between 1995 and 2001 we adopted the practice of anterior radical surgery combined with instrumentation (mesh cages and modern multisegment hook/screw system), and employed this approach in 102 patients. Of these: 28 patients underwent surgery at dorsal vertebral level, 35 at dorsolumbar level, and 39 at lumbar level.

Our experience has enabled us to develop a protocol in the management of these patients depending on:

The level of vertebral involvement (cervico-dorsal/ dorsolumbar/lumbar),

In dorsal lesions involving less than two consecutive levels with no deformity, we performed anterior procedure only. In multilevel dorsal lesions with no deformity we did anterior followed by the posterior surgery. In dorsal lesions with deformity we performed Back-Front-Back procedure. In dorsolumbar lesions with single level disease we did anterior procedure only. In presence of multisegment involvement with or without deformity we did Back-Front-Back procedure. In lumbar lesions with anterior and middle column involvement without deformity we performed anterior surgery only. In lumbar lesions with all column involvement with deformity we performed anterior and posterior surgery.

Results: With the use of instrumentation we achieved satisfactory results in terms of correction of deformity. We were also able to carry out extensive debridement (with anticipation of gaining stability with instrumentation), thereby clearing infection locally and effecting neurological improvement in all our cases. There were a few minor complications in our second (instrumented) group. No major complications (death, deep secondary infection or deterioration of the neurology), occurred in this group.

Conclusion: We conclude that Instrumentation in Spinal Tuberculosis is safe. It allows the surgeon to debride the tissues safely and to stabilise the spine and thus prevent deformity. Instrumentation also allows early mobilisation. The radical debridement leads to a reduction in recurrence of infection at the operative site.

Introduction and Aims: Instrumentation in spinal tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem.

Method: We operated on 147 patients with spinal tuberculosis between 1990 and 2001. Between 1990 and 1995, we treated 45 patients in the traditional manner with anterior decompression and strut grafting. We encountered an unacceptably high rate of complications, such as graft collapse, progression of deformity and pseudoarthrosis. Between 1995 and 2001, we adopted the practice of anterior radical surgery combined with instrumentation (mesh cages and modem multi-segment hook/screw system), and employed this approach in 102 patients. Of these: 28 patients underwent surgery at dorsal vertebral level, 35 at dorsolumbar level, and 39 at lumbar level.

Results: Our experience has enabled us to develop a protocol in the management of these patients depending on a) the level of vertebral involvement (cervicodorsal/dorsolumbar/lumbar); b) the presence of single or multilevel disease; and c) location of disease in the spinal columns.

In dorsal lesions involving less than two consecutive levels with no deformity, we performed anterior procedure only. In multilevel dorsal lesions with no deformity we did anterior followed by posterior surgery. In dorsal lesions with deformity we performed Back-Front-Back procedure. In dorsolumbar lesions with single-level disease we did anterior procedure only. In the presence of multi-segment involvement with or without deformity we did Back-Front-Back procedure. In lumbar lesions with anterior and middle column involvement without deformity we performed anterior surgery only. In lumbar lesions with all column involvement with deformity we performed anterior and posterior surgery.

With the use of instrumentation we achieved satisfactory results in terms of correction of deformity. We were also able to carry out extensive debridement (with anticipation of gaining stability with instrumentation), thereby clearing infection locally and effecting neurological improvement in all our cases. There were a few minor complications in our second (instrumented) group. No major complications (death, deep secondary infection or deterioration of the neurology) occurred in this group.

Conclusion: We conclude that instrumentation in spinal tuberculosis is safe. It allows the surgeon to debride the tissues safely and to stabilise the spine and thus prevent deformity. Instrumentation also allows early mobilisation. The radical debridement leads to a reduction in recurrence of infection at the operative site.

Instrumentation in Spinal Tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem.

We operated on 127 patients with Spinal Tuberculosis between 1990 and 2000. Between 1990 and 1995, we treated 45 patients in the traditional manner with anterior decompression and strut grafting. During this period we encountered an unacceptably high rate of complications, such as graft collapse, progression of deformity and pseudoarthrosis.

Between 1995 and 2000, we adopted the practice of anterior radical surgery combined with instrumentation, and employed this approach in 82 patients. Of these:

18 patients underwent surgery at dorsal vertebral level, 30 at dorsolumbar level, and 34 at lumbar level.

Our experience has enabled us to develop a protocol in the management of these patients depending on:

a/ the level of vertebral involvement (cervicodorsal/ dorsolumbar/ lumbar),

b/ the presence of single or multilevel disease, and

c/ location of disease in the spinal columns.

In Dorsal lesions involving less than two consecutive levels with no deformity, we performed anterior procedure only. In multilevel dorsal lesions with no deformity we did anterior followed by posterior surgery. In Dorsal lesions with deformity we performed Back-Front-Back procedure. In single level Dorsolumbar lesion we did anterior procedure only. In presence of multisegment involvement with or without deformity we did Back-Front-Back procedure. In Lumbar lesion with anterior and middle column involvement without deformity anterior surgery was performed. In presence of all column involvement with deformity we did anterior followed by posterior surgery.

With the use of instrumentation we achieved satisfactory results in terms of correction of deformity. We were also able to carry out extensive debridement (with anticipation of gaining stability with instrumentation), thereby clearing infection locally and effecting neurological improvement in all our cases. There were a few minor complications in our second (instrumented) group. No major complications (death, deep secondary infection or deterioration of the neurology), occurred in this group.

We conclude that Instrumentation in Spinal Tuberculosis is safe. It allows the surgeon to debride the tissues safely and to stabilise the spine and thus prevent deformity. Instrumentation also allows early mobilisation. The radical debridement leads to a reduction in recurrence of infection at the operative site.