1
|
Shimogawa T, Mukae N, Kanata A, Tsukamoto H, Murakami N, Kurogi A, Shono T, Suzuki SO, Morioka T. Spinal cord deformity with aggravation of tethering in saccular limited dorsal myeloschisis during the first 2 months of life. Surg Neurol Int 2021; 12:476. [PMID: 34621591 PMCID: PMC8492443 DOI: 10.25259/sni_517_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/01/2021] [Indexed: 11/04/2022] Open
Abstract
Background Although the optimal timing of prophylactic untethering surgery for limited dorsal myeloschisis (LDM) with intact or subtle neurological findings diagnosed at birth remains undetermined, intentional delayed surgery is commonly used for flat and tail-like LDM. Conversely, for saccular LDM, early surgery is indicated during the postnatal period because it prevents rupture of the sac. We treated a saccular LDM patient, in whom intentional delayed surgery was selected because the sac was thickly covered with normal skin. We describe the clinical course of the case and discuss the optimal timing of the surgery. Case Description The patient had a dorsal midline sac in the upper lumbar region. Initial magnetic resonance imaging (MRI) after birth revealed a tethering tract that began at the dome of the sac and joined the lumbar cord. Dorsal bending of the cord at the stalk-cord union and invagination of the cord into the sac were noted. At 2 months, he was neurologically normal; however, the second MRI examination revealed that the cord tethering was aggravated. The cord was markedly displaced dorsally and to the left, with deviation of the cord to the sac out of the spinal canal. Following untethering surgery, the spinal cord deformity markedly improved. Conclusion Early surgery may be recommended for saccular LDM when tethering is present, including dorsal bending of the cord at the stalk-cord union and invagination of the cord into the sac observed on detailed MRI examination, even if the sac has no risk of rupture.
Collapse
Affiliation(s)
- Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Kanata
- Department of Neurosurgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Haruhisa Tsukamoto
- Department of Neurosurgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ai Kurogi
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Tadahisa Shono
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
| | | | - Takato Morioka
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
| |
Collapse
|
2
|
Morioka T, Murakami N, Suzuki SO, Mukae N, Shimogawa T, Kurogi A, Shono T, Mizoguchi M. Surgical histopathology of a filar anomaly as an additional tethering element associated with closed spinal dysraphism of primary neurulation failure. Surg Neurol Int 2021; 12:373. [PMID: 34513140 PMCID: PMC8422463 DOI: 10.25259/sni_340_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/09/2021] [Indexed: 11/12/2022] Open
Abstract
Background: Closed spinal dysraphism of primary neurulation failure could be associated with filar anomalies, such as filar lipoma or thickened and tight filum terminale (TFT), resulting from impaired secondary neurulation. Retained medullary cord (RMC) is a remnant of the cavitary medullary cord originating from the secondary neurulation failure. Some filar lipomas are known to contain a central canal-like ependyma-lined lumen with surrounding neuroglial tissues (E-LC w/NGT), that is, a characteristic histopathology of RMC. To clarify the embryological background of these filar anomalies, we evaluated the histopathological findings. Methods: Among 41 patients with lesions of primary neurulation failure who underwent initial untethering surgery, the filum including cord-like structure (C-LS) was additionally resected in 10 patients (five dorsal and transitional lipomas; five limited dorsal myeloschisis). We retrospectively analyzed the clinical, neuroradiological, intraoperative, and histopathological findings. Results: Among 10 patients, two patients were diagnosed with RMC based on morphological features and intraoperative neurophysiological monitoring. The diagnosis of filar lipoma was made in six patients, since various amounts of fibroadipose tissue were histopathologically noted in the filum. Two patients were diagnosed with TFT, since the filum was composed solely of fibrocollagenous tissue. E-LC w/NGT was noted not only in both C-LSs of RMCs but also in two out of six fila both with filar lipomas and fila with TFTs. Conclusion: These findings provide further evidence for the idea that entities, such as filar lipoma, TFT, and RMC, can be considered consequences of a continuum of regression failure occurring during late secondary neurulation.
Collapse
Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan.,Department of Neurosurgery, Harasanshin Hospital, Karatsu, Saga
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | | | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka, Japan
| | | | - Ai Kurogi
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Tadahisa Shono
- Department of Neurosurgery, Harasanshin Hospital, Karatsu, Saga
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka, Japan
| |
Collapse
|
3
|
KUROGI A, MORIOKA T, MURAKAMI N, SHIMOGAWA T, MUKAE N, MATSUO Y, IMAMOTO N, TATEISHI Y, SUZUKI SO. Saccular Limited Dorsal Myeloschisis with Spinal Cord Deviation out of the Spinal Canal to the Sac. NMC Case Rep J 2021; 8:739-746. [PMID: 35079542 PMCID: PMC8769447 DOI: 10.2176/nmccrj.cr.2021-0168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/19/2021] [Indexed: 12/04/2022] Open
Abstract
Saccular limited dorsal myeloschisis (LDM) is characterized by a fibroneural stalk linking the saccular skin lesion to the underlying spinal cord. Since untethering surgery during the early postnatal period is often indicated to prevent sac rupture, saccular LDM should be distinguished from myelomeningocele (MMC) during the perinatal period. We treated two patients with the spinal cord deviation from the spinal canal to the sac, which mimicked a prolapse of the neural placode into the MMC sac. In patient 1, pre- and postnatal magnetic resonance imaging (MRI) revealed that the spinal cord was strongly tethered to the thick stalk. During surgery, the dorsally bent cord and stalk were united, and the border between these two was determined with intraoperative neurophysiological mapping (IONM). In patient 2, the spinal cord was tethered to two slender stalks close to each other, which was visible with the combined use of sagittal and axial postnatal three-dimensional heavily T2-weighted imaging (3D-hT2WI). The preoperative MRI hallmark of saccular LDM is the visualization of a stalk that links the bending cord and sac. Complete untethering surgery to return the cord into the spinal canal and correct its dorsal bending is recommended.
Collapse
Affiliation(s)
- Ai KUROGI
- Department of Neurosurgery, Fukuoka Children’s Hospital, Fukuoka, Fukuoka, Japan
| | - Takato MORIOKA
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Fukuoka, Japan
| | - Nobuya MURAKAMI
- Department of Neurosurgery, Fukuoka Children’s Hospital, Fukuoka, Fukuoka, Japan
| | - Takafumi SHIMOGAWA
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Nobutaka MUKAE
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Yoshihiro MATSUO
- Department of Neurosurgery, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
| | - Naoyuki IMAMOTO
- Department of Neurosurgery, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
| | - Yuki TATEISHI
- Department of Pathology, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
| | | |
Collapse
|
4
|
Murakami N, Morioka T, Suzuki SO, Mukae N, Shimogawa T, Matsuo Y, Sasaguri T, Mizoguchi M. Clinicopathological findings of limited dorsal myeloschisis associated with spinal lipoma of dorsal-type. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
5
|
Morioka T, Murakami N, Suzuki SO, Takada A, Tajiri S, Shimogawa T, Mukae N, Iihara K. Neurosurgical Pathology and Management of Limited Dorsal Myeloschisis Associated with Congenital Dermal Sinus in Infancy. Pediatr Neurosurg 2020; 55:113-125. [PMID: 32615563 DOI: 10.1159/000507867] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Because of the shared origin of limited dorsal myeloschisis (LDM) and congenital dermal sinus (CDS), CDS elements may be found within the fibroneural LDM stalk. When part of the CDS invested in the intradural stalk is left during untethering surgery, inclusion tumors such as dermoid cysts may develop. However, the most appropriate surgical strategy for LDM with CDS is still under debate. METHODS Of 19 patients with LDM, 3 (15.8%) had histologically verified CDS elements. We retrospectively analyzed the clinicopathological findings of these patients. RESULTS In patient 1, the entire stalk including a tiny dermoid cyst at the intradural stalk could be resected through two-level laminectomy during untethering at 6 months of age. In patients 2 and 3, the stalk appeared to be a typical LDM stalk during the initial surgery at 18 and 7 days, respectively; however, CDS was histologically diagnosed in the proximal severed end of the stalk. Postoperative three-dimensional heavily T2-weighted imaging demonstrated spherical enlargement of the remnant stalk, and the entire length of the remnant stalk including newly developed dermoid was resected during the second surgery at 3 years 11 months and 11 months, respectively. Histopathologically, glial fibrillary acidic protein-immunopositive neuroglial tissues and CDS elements were mainly located at the proximal and distal sites of the stalk, respectively, supporting the "dragging down and pulling up" theory. In patients 2 and 3, however, the proximal head of the dermoid cyst passed the distal head of the neuroglial tissues and located at the stalk-cord attachment. CONCLUSION Surgeons should be aware of the approximately 10% possibility of the coexistence of CDS when managing infant LDM. However, the recommendation for excision of the entire length of the LDM stalk in all patients should be more carefully made because such a strategy may result in an unnecessary extent of laminotomy/laminectomy for most patients with pure LDM. However, once the postoperative histological examination reveals coexistence of CDS in the resected proximal part of the stalk, the entire length of the remnant stalk should be excised as soon as possible.
Collapse
Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan,
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Takada
- Department of Neurosurgery, Kumamoto City Hospital, Kumamoto, Japan
| | - Seiji Tajiri
- Department of Neurosurgery, Kumamoto City Hospital, Kumamoto, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
6
|
Morioka T, Murakami N, Ichiyama M, Kusuda T, Suzuki SO. Congenital Dermal Sinus Elements in Each Tethering Stalk of Coexisting Thoracic Limited Dorsal Myeloschisis and Retained Medullary Cord. Pediatr Neurosurg 2020; 55:380-387. [PMID: 33271568 DOI: 10.1159/000511876] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 09/19/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The embryogenesis of limited dorsal myeloschisis (LDM) likely involves impaired disjunction between the cutaneous and neural ectoderms during primary neurulation. Because LDM and congenital dermal sinus (CDS) have a shared origin in this regard, CDS elements can be found in the LDM stalk. Retained medullary cord (RMC) is a closed spinal dysraphism involving a robust, elongated, cord-like structure extending from the conus medullaris to the dural cul-de-sac. Because the RMC is assumed to be caused by impaired secondary neurulation, concurrent RMC and CDS cannot be explained embryologically. In the present article, we report a case in which CDS elements were noted in each tethering stalk of a coexisting LDM and RMC. CASE PRESENTATION A 2.5-month-old boy with left clubfoot and frequent urinary and fecal leakage had 2 tethering tracts. The upper tract, which ran from the thoracic tail-like cutaneous appendage, had CDS elements in the extradural stalk and a tiny dermoid cyst in the intradural stalk immediately after the dural entry. In the lower tract, which ran from the lumbosacral dimple, the CDS as an extradural stalk continued to the RMC at the dural cul-de-sac. Both stalks were entirely resected through skip laminotomy/laminectomy at 1 stage to untether the cord and resect the CDS elements. CONCLUSION Surgeons should be aware that CDS elements, in addition to LDM, may coexist with RMC that extends out to the extradural space.
Collapse
Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan, .,Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan,
| | - Nobuya Murakami
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Masako Ichiyama
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takeshi Kusuda
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Psychiatry, Shourai Hospital, Saga, Japan
| |
Collapse
|