Tuberculosis of the craniovertebral region is very rare. Neural deficit in this region is reported in between 24% and 64% of cases, and mainly takes the form of quadriparesis. Hemiplegic and monoplegic presentation among this set of patients is rarer. Out of 32 patients treated at our institution between May 1989 and February 2001, only one had hemiplegia, while two had monoplegia. These three cases are discussed. Case 1 involved a 45-year-old woman who presented with hemiplegia following a trivial fall. Plain radiographs and computed tomographic (CT) scans of the skull appeared normal, but CT scans of C1-C2 and the craniovertebral junction revealed destruction of the dens and atlantoaxial subluxation. The patients in cases 2 and 3 had monoplegia. Plain radiographs in both cases showed an increased prevertebral soft tissue shadow in front of C1-C2. CT in case 2 and magnetic resonance imaging (MRI) in case 3 revealed destruction of the arch of C1 and the dens, with subluxation. All three patients were successfully treated with rest, skull traction, anti-tubercular drugs and suitable braces. Case 3 required stabilization. All three patients achieved complete neural recovery. Patients 1, 2 and 3 had 22, 48 and 4 months' follow-up respectively. Patient 3 was subsequently transferred to a neurosurgery ward for stabilization of the occipito-C3 vertebrae. Hemi/monoplegic presentation is extremely rare; no author in the literature is able to give reason for the rarity or the pathomechanics of the condition. We believe that if medullary cervical junctional involvement extends slightly higher (in rare circumstances), with involvement of one of the branches of the vertebral or lower basilar artery, medial medullary syndrome will occur, sparing medial lemniscus and emerging hypoglossal nerve fibres. Thus the pyramids will be involved, causing contralateral hemiparesis, and if the pyramids are selectively involved, it will cause contralateral monoparesis.

The study was undertaken to establish the normal foot bimalleolar (FBM) angle in Indian infants and to correlate it with the severity of deformity and results of treatment in congenital talipes equinovarus (CTEV). Foot tracings with the level of both the malleoli of 182 feet (91 normal Indian infants) were taken. The anteromedial angle between the long axis of foot and the bimalleolar plane was taken as the FBM angle. The FBM angle in normal infants was calculated as 82.5 degrees. Eighty-four CTEV (51 patients) were clinically classified as grade I (five feet; FBM angle, 73.2 degrees), grade II (21 feet; FBM angle, 66.6 degrees), and grade III (58 feet; FBM angle, 54.7 degrees), depending on whether the foot could be passively corrected (grade I) or had a fixed equinus and/or varus of <20 degrees (grade II) or >20 degrees (grade III). Thirty-one feet (22 patients) were followed up prospectively after conservative (17 feet: grade I, three feet; grade II, three feet; grade III, 11 feet) and surgical release (all grade III, 14 feet). All feet with grade I and grade II deformity and 44% (11 feet) with grade III deformity were amenable to gentle graduated manipulations and cast application, whereas 56% (14 feet) with grade III deformity underwent soft tissue release. After nonsurgical treatment, the mean FBM angle was 82.3 degrees. Of the feet that underwent surgery, those with excellent (11 feet) and good correction (3 feet) had a mean FBM angle of 79.9 degrees and 74.3 degrees, respectively. There were no feet with fair or poor results. The clinical severity of foot deformity and results of treatment correlated well with the FBM angle. Foot tracing with the FBM angle is a simple, objective, and reproducible clinical criterion to classify the severity of foot deformity and evaluate the results of treatment.

Epidural volume extension is a technical modification of the combined spinal epidural block. It involves the epidural injection of normal saline or a small volume of local anaesthetic after an intrathecal injection, aiming to augment the post-spinal sensory level. Although the consequent sensory block augmentation has been adequately documented, the probable factors influencing epidural volume extension and its implications for clinical practice are not well defined. This article reviews published literature relating to the probable factors affecting epidural volume extension, its clinical implications, case reports of its successful clinical application and summarises its unexplored effects.

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