The clinical presentation of tethered spinal cord and the results of tethered cord release were examined in a group of 30 low motor level (L3 and below) children with a history of myelomeningocele without concomitant CNS complications. Changes in orthopedic and/or neurologic status formed the basis of consideration for tethered cord release. Clinically, these patients presented with a new onset or recently progressing scoliosis, spasticity with or without contractures, decrease in motor function and low back pain at the site of closure. One or more of these findings was present in all cases and led to the suspicion of tethered spinal cord. The diagnosis of tethered cord was confirmed in all cases by MRI or CT myeolography. In order to isolate tethering as the etiology for the patients’ clinical deterioration, patients with concomitant CNS complications, e.g. shunt dysfunction or hydromyelia were excluded from the study. Twenty-nine such patients, of an initial 59, who would have otherwise been considered, were excluded on the basis of this criteria of concomitant CNS complications. The results of release 1 year after the procedure were as follows: regarding scoliosis, in 75% of cases the curve either remained stable or decreased by more than 10°, with 25% experiencing curve progression of >10°. The most recent follow-up in this group revealed that 11.8% experienced a decrease in curvature of >10°; 47.1% remained stable, and 41.2% ultimately progressed 10°. In the group with spasticity, 43.8% improved; 56.3% remained stable, and none worsened. Most (78.6%) of the children who had experienced a decline in motor function improved postopera-tively, and all those with back pain experienced complete resolution. In conclusion, tethered cord release in symptomatic low lumbar and sacral level children with myelomeningocele appears to be of benefit, especially with respect to stabilization of scoliosis in selected patients, back pain at the site of closure, and prior decline in motor function. Results in the cases with spasticity were more equivocal.

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The results of the surgical treatment of clubfoot deformity in spina bifida by radical posteromedial-lateral release (PMLR) are presented. In all cases, the Cincinnati incision was used and the tendons excised, including the anterior tibial tendon. In 21 feet, a special K-wire was used to derotate the talus in the ankle mortise. The minimum follow-up was 2 years. The average age at surgery was 14 months. The overall results showed 63% good, 14% fair, and 23% poor results. In the 21 feet in which the talus K-wire was used, 76% had a good result, 14% fair, and 10% poor. The results were also analyzed based on the motor level. In the thoracic/high lumbar level, 50% had a poor result. In the low lumbar and sacral level groups together, of 45 feet, five had a poor result. This study shows that a radical PMLR can produce an overall good and fair result in 77% of the cases. The use of the K-wire to derotate the talus led to an improvement in the result. The tendon excision leading to a flail foot corrects any residual muscle imbalance. The poor results seen in the thoracic/high lumbar patients are likely to be related to the lack of weight bearing in view of their motor paralysis.

RESUMOEste estudo examina a influência da instabilidade unilateral do quadril sobre a marcha de pacientes portadores de mielomeningocele, nível lombar baixo e instabilidade unilateral do quadril.Foram estudados através da análise laboratorial de marcha, 20 pacientes deambuladores comunitários utilizando goteiras e muletas, com luxação ou subluxação unilateral do quadril. , Os pacientes foram sub divididos em dois grupos. Grupo 1 (10 pacientes) , que não apresentavam contraturas do quadril (flexão e/ ou adução) ou as apresentavam de forma simétrica entre os lados; e Grupo 2 (10 pacientes), que apresentavam contraturas assimétricas de quadril A cinemática do quadril e da pelve foi analisada no sentido de se avaliar a simetria entre o lado envolvido e o oposto. Sete pacientes do Grupo 1 e 2 do Grupo 2 apresentaram marcha simétri-ca. Marcha assimétrica foi encontrada em 3 pacientes do Grupo 1 e 7 pacientes do Grupo 2. A assimetria na marcha relacionou-se principalmente com a presença de contraturas de quadril unilaterais ou bilaterais mas assimétricas.Demonstrou-se que a assimetria da marcha não pode ser atribuída somente à instabilidade do quadril, mas parece estar mais relacionada com presença de contraturas unilaterais ou assimétricas e cujo tratamento deveria ser o objetivo em detrimento de reduções cirúrgi-cas do quadril. Descritores: Mielomeningocele; Luxação do quadril; Marcha INTRODUÇÃOA mielomeningocele é um dos defeitos de fechamento do tubo neural que resulta em déficit neurológico distal à lesão. Os pacientes podem ser classificados de acordo com o nível neurológico em torá-cico, lombar alto, lombar baixo e sacral (8) . Pacientes de nível lombar baixo tipicamente mostram força muscular grau 3 ou maior em quadríceps e isquiotibiais mediais, mas não apresentam função da musculatura glútea.Os avanços no manejo neurocirúrgico e urológico destes pacientes têm aumentado sua expectativa de vida e o desenvolvimento e SUMMARY This study examines the influence of unilateral hip dislocation or subluxation in the gait of 20 low-lumbar myelomeningocele patients, community ambulators with AFOs and crutches, utilizing gait analysis.