Purpose of the study: Diastematomyelia is a rare spinal cord malformation defined as the presence of two separate spinal cords separated or not by an osseous, cartilaginous, or fibrous septum. Spinal malformations are almost always associated, raising difficult therapeutic challenges.

Material and method: We report three cases of congenital kyphoscoliosis associated with diastematomyelia in three girls aged 12, 14 and 15 years. The diastematomyelia was dorsal in one case, thoracolumbar in one and lumbar in the third. For all three patients, the indication for surgery was progression of the scoliosis with development of neurological signs of recent progressive aggravation. Preoperative distraction with a plaster cast was pursued for several months prior to posterior instrumentation. No attempt was made to correct the cord malformation nor achieve major correction of the spinal malformation. The instrumentation bridged the thoracolumbar scoliosis in one case and stopped above the malformation in the two others.

Results: The postoperative period was uneventful. There were no neurological complications. Preoperative neurological signs improved after surgery. Control radiographs showed an improvement in the deformity. At mean 6 years follow-up, these patients were not bothered in their everyday life. They had stable deformities which a globally balanced trunk. There were no signs of neurological evolution.

Discussion: The therapeutic strategy for diastematomyelia remains a subject of debate. For some authors, the spinal cord should be released systematically which for the majority, this is not necessary except if spinal distraction is planned or if there is a neurological problem. If there is an indication for spinal cord release, any spurs must be removed followed by the necessary dura mater plasty. In our three patients, and in agreement with the neurosurgery team, there was no need for neurosurgical release. The recent development of neurological deficits was explained by the important kyphosis rather by the intramedullary anomaly. Our therapeutic strategy thus focused on treatment of the scoliosis. This enabled us to stabilise the spine, protecting these patients from worsening neurological involvement and enabling good functional outcome. The zone of the malformation was not instrumented in all cases because the posterior arcs were deformed, but also to avoid compromising any future neurosurgical intervention.

Introduction: Surgical treatment of thoracolumbar spine fractures from T11 to L2 with correction of the traumatic kyphosis should be expected to avoid the deceptions observed with former treatments.

Material and methods: Seventy trauma victims (41 men and 29 women) underwent surgery between 1996 and 2003. According to the Denis classification, they presented: 16 compressions, 43 burst fractures, 8 seat belt fractures, and 3 disclocations. The Frankel classification was E:62, A:2, C2, D:2. Mean follow-up was 30.7 months. A pedicle screw protected with sublaminal hooks below and pediculotransverse claws above was used in 50 patients with a hybrid configuration in 20. Reduction was achieved by in situ cerclage. A secondary anterior graft was implanted for 38 patients.

Results: Patients were allowed to rise without contention on day 3. The traumatic angle measured with the sagittal index of Farcy (SIF) (the quality parameter used to study reduction) was 17 preoperatively and 1.6 after surgery. The loss at last follow-up was −2.2° with 81% of patients presenting normal or over correction. The loss was greatest (5.2°) for uniquely posterior approaches. The final Oswestry score was 29.8 (range 6–80) with a better result for the double approaches (20.7 versus 37.4, p< 0.001). Complications were phlebitis (n=1), sutured dural breaches (n=2), disassembly and nonunion (revision with a double approach) (n=1), infection (treated by wash-out and antibiotics) (n=10), retroperitoneal hematoma (treated by embolization) (n=1). Thirty-two patients resumed their work at seven months on average and 13 did not (25 without professional occupation).

Discussion: The overall results are better than those after orthopedic treatment. The rate of resumed work was 71%. This is an excellent result with a less aggressive treatment protocol (no corset) and shorter hospital stay (5–19 days). The protective hooks facilitate in situ cerclage, avoiding catching the screws and the risk of disassembly. The anterior graft is necessary when the reduction is discal and reduces the angle loss leading to less morbidity.

Conclusion: In situ cerclage enables constant sustained reduction of thoracolumbar fractures. Indication for surgery is often retained because of major deformation. Spinal fractures should be examined with the same assessment criteria as used for fractures of long bones and weight bearing should begin early to avoid the risks associated with prolonged bed rest.