Paediatric spinal cases turn on timing more often than technique. Neurological deficit that is recognised and decompressed early frequently recovers; the same deficit left for weeks frequently does not. That makes the documented sequence of symptoms, examinations and imaging decisions the heart of most instructions.

Clinical basis for the opinion

I manage paediatric spinal cases as part of my consultant practice, across the range of congenital and acquired conditions seen in a tertiary centre.

I have published as first author on paediatric spinal neurosurgery in the peer-reviewed literature, including a ten-year single-centre review of intramedullary spinal cord tumours and a case series of craniocervical fusion in children, both in the British Journal of Neurosurgery. Both concern conditions in which delayed diagnosis and surgical decision-making are frequently in issue.

Issues commonly in dispute

Instructions in this area most often turn on one of the following.

Delayed diagnosis of tethered cord

Whether the presenting features — deteriorating gait, changes in bladder or bowel function, foot deformity, back or leg pain — should have prompted imaging and referral earlier, and whether earlier untethering would have altered the neurological outcome.

Missed or delayed spinal cord compression

Where compression arises from tumour, infection or trauma, the dispute is usually about the interval between first presentation and decompression, and what neurological recovery would have followed had that interval been shorter.

Spina bifida and spinal dysraphism

Antenatal and postnatal management, timing of closure, recognition and treatment of associated hydrocephalus, and long-term neurosurgical surveillance.

Intramedullary spinal cord tumours

Diagnosis, the extent of resection attempted, intraoperative neurophysiological monitoring, and the balance struck between resection and preservation of function.

Craniocervical junction abnormalities

Indications for fusion, the choice of construct, and the management of instability.

Perioperative complications

New or worsened deficit after spinal surgery, wound and CSF complications, and the adequacy of postoperative monitoring and escalation.

What can and cannot be addressed

Instructions are accepted on a records and papers basis. Opinion is therefore provided on breach of duty and causation, and on prognosis so far as it can be addressed from the records.

Claimants are not examined, so condition and prognosis reports that depend on examination are a separate instruction — in paediatric neurosurgical claims usually to a paediatric neurologist, neurorehabilitation physician or paediatrician. Where a case requires both, instructing solicitors generally instruct separately for the breach and causation issues and for condition and prognosis.

Opinion is confined to paediatric neurosurgical practice. Matters turning principally on neuroradiological interpretation, paediatric neurology or neurorehabilitation are better directed to an expert in the relevant field, and will be identified as such at the enquiry stage rather than after papers have been sent.

Records that assist

The material that most affects the quality of the opinion in this area is:

The complete spinal neurosurgical record, including all previous spinal procedures
All spinal imaging with formal radiology reports, and any antenatal imaging where relevant
Operation notes and any intraoperative neurophysiological monitoring records
Serial neurological examinations, including community and physiotherapy records
Continence and urology records where bladder or bowel function is in issue
GP and school health records documenting the onset and progression of symptoms
Any statements describing functional change over time

If material appears to be missing this is raised before work begins rather than qualified in the report.

Basis of instruction

Instructions are accepted from claimant and defendant solicitors, from insurers, and as a single joint expert. Reports are prepared in accordance with Part 35 of the Civil Procedure Rules, Practice Direction 35 and the Civil Justice Council's Guidance for the Instruction of Experts in Civil Claims, and carry a statement of truth and the expert's declaration of duty to the court.

Reports are typically prepared within four to six weeks of receipt of all relevant papers. Answering Part 35 questions, taking part in experts' discussions and joint statements, and attending conference with counsel are all within scope.

Paediatric Spinal Disorders