How much sway is significant for a traditional Romberg test has always been open to interpretation and debate. Prospective and detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.

Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.

The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a pro-prioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Introduction: There is still no standard approach to applying the Romberg test in clinical neurology and the criteria for and interpretation of an abnormal result continue to be debated.

Methods: Detailed clinical examination of 50 consecutive patients of cervical myelopathy was performed prospectively. For the walking Romberg sign, patients were asked to walk five metres with their eyes open. This was repeated with their eyes closed. Swaying or inability to complete the walk with eyes closed was interpreted as a positive walking Romberg sign. This test was compared to common clinical signs to evaluate its relevance.

Results: Whilst the Hoffman’s reflex (79%) was the most prevalent sign, the walking Romberg sign was present in 74.5% of the cases. The proprioceptive deficit was evident by only using the walking Romberg in 21 out of 38 patients that had a positive Romberg sign. Though not statistically significant, the mean 30 metre walking times were slower in patients with standing Romberg test than in those with positive walking Romberg test and fastest in those with neither of these tests positive. The combination of either Hoffman’s reflex and/or Walking Romberg was positive in 96% of patients.

Conclusion: The walking Romberg sign is more useful than the standing Romberg test as it shows evidence of a proprioceptive gait deficit in significantly more patients with cervical myelopathy than is found on conventional neurological examination. The combination of Hoffman’s reflex and walking Romberg sign has a potential as useful screening tests to detect clinically significant cervical myelopathy.

Ethics approval: none

Interest statement: none

Introduction: Malrotations following Several complications have been reported in femoral nailing, among them. The aim of this study is to develop an intraoperative method based on cone beam CT (CBCT) to assess comminuted fracture periaxial rotation. We hypothesize that bone surface matching using CBCT image data can precisely predict malrotation in the fractured femur even with severe comminution.

Methods: A mid-shaft osteotomy in a fresh frozen cadaveric femur was performed and a rotational axis was formed. The proximal part of the femur was fixed and the distal part was optically racked for periaxial rotation. At each rotation a CBCT was aquired. The images were segmented at bone threshold. The center of the bone in each axial slice was calculated and the distance from that center to the inner and outer bone surfaces was sampled at 1o intervals (360x). The resulting plot was an unwrapped virtual bone surface consisting of a pattern of ridges and valleys. Fracture gaps were simulated by removing CT slices adjacent to the osteotomy. The fracture gap was reconstituted using an extrapolation algorithm to the midline of the fracture. The two bone surfaces were then continuously shifted relative to one another in order to match the geometric bony features. Calculated malalignments were compared to the measured at each of the 16 rotations with each of the 9 simulated fracture gaps. Three rotational malrotations were tested twice to assess repeatability.

Results: Femoral malrotation was strongly predicted as compared to the rotation measured by optical tracking. The performance was not impacted by gap size up to 100 mm.

Discussion: The high quality of intraoperative CBCT imaging data enables surface matching algorithms to be utilized. The results ratify this novel method for assessing fracture rotation.

Study Design: Review of patients with massive disc prolapse, with a minimum of 50% canal occlusion, treated non-operatively.

Objectives: To demonstrate the behaviour of massive disc prolapse treated non-operatively.

Subjects: Patients with massive disc prolapse whose symptoms had started to resolve or who had refused surgery.

Outcome Measures: Spontaneous reduction of disc herniation on MRI scans.

Results: There were 10 patients who have had massive lumbar disc prolapse treated non-operatively. All had MRI scans which showed a lumbar disc prolapse occluding greater than 50% of the canal diameter on the axial cuts. The average occlusion of the canal was 62%. Repeat MRI scans showed reduction of the disc prolapse in all cases, with an average of 83% (range 68–100) reduction in the canal occlusion. The scans were performed between 6 and 68 months apart. 9/10 patients had resolution of leg pain. One patient had persistent leg pain despite complete resolution of the disc prolapse. He went on to have an exploration of the right S1 nerve root. No disc prolapse was identified and the S1 root was free and healthy. This however resolved the majority of his leg pain.

Conclusion: We have demonstrated that the natural history, in these cases of massive prolapse was to resolve both clinically and radiologically in the majority of cases.

Problem Chronic disabling pain in the sacrococcygeal region is regarded by clinicians with great dismay because of unpredictability of the treatment outcome. The subject is under- represented in the literature.

Method Thirty eight patients with intractable coccydynia had imaging investigations for the spine other than X-rays. Six of these patients were also investigated by means of sacrococcygeal and intercoccygeal discography. The excised specimen with intact sacrococcygeral joint was sent for histological examination in 22 patients. Patients’ assessment of the benefit of coccygectomy was conducted by telephonic interview.

Results After a mean post surgical follow up of 6.75 years (range 2–16 yrs), results were available for 31 out of 38 patients.

16 patients benefited greatly from the surgery and 6 benefited to some extent, giving an overall good result of 71%. 7 patients had no or little relief from surgery (29%).

Moderate to severe degenerate changes in SC and IC joints on histology were found in 59% of patients. 91.6 % of these patients did well with surgery. Only 60 % of those with mild changes did well.

Discography was possible in five out of six attempted cases. Two were positive and both did well from surgery. Three patients had negative discographies and two of them had a poor result and one had only some relief.

Conclusions Degenerate changes in sacrococcygeal discs give rise to pain. Surgical results are better in those with a severe degree of degenerative change. It is possible to identify these with discography, though a larger study needs to be carried out.

Introduction: Selective dorsal rhizotomy has been used extensively in Europe and North America in the management of spasticity secondary to cerebral palsy. Permanent reduction in lower limb spasticity has been observed with consequent improvements in gait parameters. A decade ago a rhizotomy programme was established in Oswestry to utilise the technique for a carefully monitored group of children with cerebral palsy diplegia.

Methods: Using stringent selection criteria, twenty children underwent selective lumbar dorsal rhizotomy with follow up by means of gait analysis. A permanent reduction in spasticity has been observed with a significant improvement in almost all parameters. We report the need for further bony and soft tissue surgery and our complications. There has been weight gain in the majority of cases. There has been no major spinal deformity.

Conclusion: As a result of our review of the results in the first twenty cerebral palsy diplegic patients we have modified our selection criteria. Exclusion criteria include weakness, not enough spasticity or poor control.

Introduction: The incidence of scoliosis in patients with myelomeningocele has been reported to be as high as 80 to 90% in some studies. However these studies included patients with both congenital and developmental curves. The purpose of this study is to identify clinical and radiological factors, which may predict the development of scoliosis in patients with myelomeningocele.

Methods: A retrospective review of the charts and radiographs of all patients with myelomeningocele seen in our clinic between 1990 and 1995 was performed. Selection criteria for the study included: a diagnosis of myelo-meningocele or lipomeningocele, age greater than 10 years, serial documentation of motor power testing, and a radiographic documentation of spinal deformity primarily in the coronal plane.

Statistical analysis was performed to obtain predictive values, specificity and sensitivity for each of the following factors: clinical motor level, functional status, motor asymmetry and hip instability.

Radiographs were examined to obtain the last intact laminar arch in these patients. The relationship between the last intact laminar arch and scoliosis was evaluated.

Results: 141 patients satisfied the inclusion criteria. Seventy-four patients (53%) developed scoliosis. The mean follow-up was 9.4 years (range 3–30 years). The average age of the patient population was 19 (range 10–42 years). Forty-three patients developed scoliosis before nine years of age. New curves continued to develop until 15 years of age. Curves less than 20° often resolved. Clinical motor level, functional status, motor asymmetry and the last intact laminar arch were all found to be predictive for scoliosis in these patients. The presence of spasticity and hip instability had no definite influence on the development of scoliosis.

Conclusion: The term scoliosis should be reserved for curves greater than 20° in patients with myelomeningocele. New curves may continue to develop until 15 years of age. The last laminar arch is a useful early indicator of scoliosis in these patients.

Objective: To establish the anatomy of the iliolumbar vein.

Design: Prosections of human cadavers were examined.

Subjects: Sixteen iliolumbar veins in eight cadavers. Outcome measures: Width, length, pattern of drainage, tributaries, distance from IVC to the iho lumbar vein, structures drained and immediate relations. The risk of avulsion on great vessel retraction to expose the L4/L5 disc.

Results: Two variants encountered; a single vein an average 3.74cms from the IVC (11/16), or two stems, an average of 2.98cms to the proximal and 6.04cms to the distal (5/16). All 16 veins tore on great vessel retraction. In all veins the obturator nerve was found to cross superficially an average 2.76cms lateral to the mouth, in four cases, the actual distance was less than 1.5cms. In 15 veins the lumbosacral trunk crossed deep, in one superficial. The average distance from the mouth was 2.5 cms, in three veins the actual distance was 1cm or less.

Conclusion: This study confirms variability in the vein with vulnerability to avulsion on retraction of the great vessels. The close relationship with the obturator nerve and lumbosacral trunk further emphasise the need for proper exposure of the vein prior to ligature and safe surgical exposure of the anterior lumbar spine. Other findings are also presented.

We carried out a cadaver study of 16 iliolumbar veins in order to define the surgical anatomy. Two variants were found; a single vein at a mean distance of 3.74 cm from the inferior vena cava (11 of 16) and two separate draining veins at a mean distance from the vena cava of 2.98 cm for the proximal and 6.24 cm for the distal stem (5 of 16). Consistently, the proximal vein tore on attempted medial retraction of the great vessels. The mean length of the vein was 1.6 cm and its mean width 1.07 cm. Three stems were shorter than 0.5 cm. Two or more tributaries usually drained the iliacus and psoas muscles, and the fifth lumbar vertebral body. The obturator nerve crossed all veins superficially at a mean of 2.76 cm lateral to the mouth. In four of these, this distance was less than 1.5 cm. Usually, the lumbosacral trunk crossed deep, at a mean distance of 2.5 cm lateral to the mouth, but in three veins, this distance was 1 cm or less.

Our findings emphasise the need for proper dissection of the iliolumbar vein before ligature during exposure of the anterior lumbar spine.

We report the technique and early results of the Dwyer-Hartshill method for segmental fixation of the spine. This uses pedicular screws wired to a rectangular frame and is indicated after laminectomy.

We report and discuss a combined anterior, anterolateral and posterior approach to the lower cervical spine. This was used for the radical resection of a recurrent osteoblastoma which involved the lateral mass, pedicle, and lamina of the sixth cervical vertebra.

A new technique is described for extra-articular subtalar arthrodesis; it combines the main elements of the Batchelor and the Grice procedures. Results were reviewed after a minimum of three years. Of the 25 feet treated 24 had solid fusion and had maintained the operative correction of the valgus deformity; the one non-union was due to deep infection.

Talectomy was performed on 10 patients (15 feet) for club foot deformity in arthrogryposis multiplex congenita. These were reviewed after an average follow-up of eight years. At follow-up nine feet were plantigrade, and six had less than 15 degrees residual equinus at the ankle. All the feet were asymptomatic but had mild residual adduction of the forefoot and marked stiffness of the hindfoot. Seven feet developed spontaneous bony ankylosis in the tibiotarsal joint. The common technical errors were incomplete removal of the talus and incorrect positioning of the calcaneus in the ankle mortise.