The patient came from YAR 22-October-2007 with parents, who noticed, that he has difficulty of walking since he started to walk. MRI performed 29-August-2007 showing intradural mass extending from L3 down to S3 with tethered cord.

On examination, which was hard to estimate, because the age of the patient was free. He had no apparent neurological deficit, including the micturition and defecation functions. He had bilateral flat feet and the parents noticed deterioration of walking.

The patient was sent to perform MRI of the cervico-medullary junction to rule out the presence of associated anomalies, which proved to be normal.

Under Highline Inomed ISIS IOM, MEP, SEP, DRAP, after application of stimulating electrodes to the penis and recording electrodes around the anal sphincter. Anesthesia was guided with pump infusion of fentanyl 0.05  µ g/Kg/h and tracorium 0.02  µ g/Kg/h and ketamine 0.02  µ g/Kg/h with N2O 40%. No inhalational material was used. Block laminotomy of L2-L5 was done and reflected upward.
Longitudinal incision of the dura and midline of the posterior aspect of the mass after confirming the absence of any neural tissues. It came evident, that the mass is intramedullary with the conus medullaris pushed down with epidermoid is the mass. The epidermoid was totally resected and the wall was meticulously cleaned off. There was a hair inside the mass, which was whitish and soft in consistency. Continuous EMG was running during the operation, which ruled out any surgical damage to the neural structures. anal M-wave was obtained several times and and at the end of the operation, SEP and MEP were performed and stimulation of the penis could give good SEP from G1 and G2 recording electrodes. Using MEP with low stimulation it was possible to record the contraction of the anus.
Untethering of the spinal cord at its lower end from the left side with dissection all the dorsal and ventral roots and rootlets and the upper part of the abnormal spinal cord was dissected of the stuck dura until the CSF came free all around. Routine closure with smooth postoperative recovery.

The patient has good sensation in the anal region.

The case is very interesting and challenging from the electrophysiological point of view. CNAP almost impossible to perform due to small length of the roots. It was felt that a qualified personnel must be appointed to perform the electrophysiological monitoring and the neurosurgeon cannot do surgery and jump to perform the various tasks, needed at various steps of the operation.

The anesthesia protocol was successful and it will be intended to be used to children in the future.