Congenital dermal sinus of the cervical spine in an adult

Cervical Dermal Sinus Tract: A Case Report and Comprehensive Literature Review

The cervical and thoracic dermal sinuses are rare entities, conforming epithelium-lined tracts that extend from an opening in the skin through a corridor to the layers of the spinal cord. They are commonly detected in early childhood; however, adult reports are singularly rare, especially in cervical regions. We report a very unusual case of a 45-year-old Mexican female who developed progressive left-side weakness and dexterity suffered from childhood, getting worse in the last year. Physical examination revealed a soft, congenital round cystic lesion in the dorsal-midline skin at the level of C4-C5 vertebrae with no previous treatment received. MRI showed a dermal sinus tract at the C4 level from the skin tethering to the spinal cord and syringomyelia. CT scan showed a dysraphism corresponding to spina bifida at the C4 level and an incomplete closure at the C3 and C5 vertebrae. We surgically managed the lesion by microscopic resection with C3-C5 laminectomy preserving strength and sensitivity. Follow-up MRI showed no residual lesion and contained fistula with no further complications. Cervical dermal sinus lesions are unusual entities, even less prevalent in adulthood. It represents a possible delay in diagnosis and an increased rate of complications. Early suspicion of the condition is required to make an accurate diagnosis since it is a potentially treatable lesion with a high risk of sequelae without surgical treatment.

Complete resection and untethering of the cervical and thoracic spinal dermal sinus tracts in adult patients

Dermal sinus tracts (DSTs) of the cervical and thoracic spine are extremely rare, particularly in adult patients because diagnosis is typically made in the early stage after birth by pediatricians. These cases should be treated surgically as soon as possible to prevent neurological sequelae. This report describes two rare adult cases with cervical and thoracic spine DSTs. The first patient presented with back pain and headache, whose skin lesion had been long known, but disregarded since birth. The second patient had long suffered from residual cervical myelopathy from the prior incomplete surgical treatment. Both cases had these sinus tracts excised completely and had spinal cord untethered successfully without any neurological deterioration. There has been a trend toward earlier diagnosis of these entities, but still some cases that were diagnosed in a delayed fashion or underwent incomplete treatment are reported. Improper management during childhood could lead to irreversible neurological deficit caused by spinal cord tethering and/or direct compression due to DSTs-associated tumors. The early detection and prompt surgical intervention improve the chance of a good surgical outcome. Furthermore, complete excision of the sinus tracts and associated tumors could help prevent future bacterial contamination and recurrence.

CONGENITAL CERVICAL TETHERED SPINAL CORD IN ADULTS: RECOGNITION, SURGICAL TECHNIQUE AND LITERATURE REVIEW. CASE SERIES

OBJECTIVE

Recognition of congenital tethered cervical cord in adults and literature review.

METHODS

Retrospective review of adult onset tethered cervical cord patients (more than 20 years of age).

RESULTS

Three adults were identified; 2 female and 1 male with an average age of 47 years. The presenting symptoms were neck pain with restricted movement (3), quadriparesis (2), sensory changes (2). Hyperreflexia was present in all these. Bony abnormalities were mainly bifid cervical spinous processes (3) and Klippel-Feil abnormalities in 1. The neurocutaneous stigmata was seen in 2. MRI revealed "limited dorsal myeloschisis" in all 3 patients. The dorsal aspect of the cervical cord extruded into the tract leading to the surface.

CONCLUSIONS

Neurocutaneous stigmata should not be considered benign. A missed clinical diagnosis was apparent in all 3 patients; 2 of whom underwent surgery with excellent results. MRI can identify the abnormal cervical cord protruding towards the "sinus tract" and allow planning to avert injury to the spinal cord during release.

Radiologically occult cervical intradural dermal sinus tract: a case report and review of literature

We report the unusual case of a 7-month-old girl presenting with congenital cervical dermal sinus tract in which the intradural tract was not detected on preoperative imaging and was identified intraoperatively. Considering possible devastating sequelae of infection, excision of dermal sinus tract might be justified even in the case with radiologically undetected intradural tract.

Cervical dermal sinus complicated with intramedullary abscess in a child: case report and review of literature

BACKGROUND

Dermal sinus tract (DST) is an uncommon spinal dysraphism presenting in childhood along the midline neuroaxis. Cervical DST less frequent is in association with intramedullary abscess.

METHODS

A 9-month-old baby was admitted to our unit suffering from right hemiparesis. Physical examination showed a cervical midline cutaneous fistula dripping a yellowish thick liquid. Cervical MRI showed at C5 level a sinus tract in continuity with a C3-C6 intramedullary lesion. Total removal of the fistula and the intramedullary lesion was performed. Histopathological examination confirmed the diagnosis of dermal sinus and abscess.

RESULTS

Post-operative cervical MRI showed a complete removal of the spinal dysraphism, fistula, and intramedullary abscess. The baby showed a progressive clinical improvement and was discharged on day 10 post-surgery.

CONCLUSION

Literature review confirms that an early diagnosis followed by prompt surgical spinal cord decompression gives a functional neurological recovery.

En bloc excision of a dermal sinus tract

Dermal sinus tracts are a form of spinal dysraphism that arises from a failure of dysjunction early in embryogenesis. They are diagnosed in pediatric patients and who present with a dimple, infection, or neurologic deficit. The tract is surgically excised en bloc to avoid contamination from the tract, which harbors bacteria. However, dermal sinus tracts typically terminate intradurally, rendering their en bloc excision difficult. To avoid entering the tract, allowing for an en bloc excision, we modified the usual technique employed for accessing the spinal intradural space. An en bloc excision of the dermal sinus tract was successfully performed. The patient recovered from the procedure neurologically intact and her postoperative course was uncomplicated. We conclude that en bloc excision of a dermal sinus tract down to the intradural space is feasible with modifications to standard operative technique.

Coexistence of a human tail and congenital dermal sinus associated with lumbosacral lipoma

We present a female baby with a human tail associated with congenital dermal sinus (CDS) at the caudal site of the tail. Magnetic resonance (MR) images with constructive interference in steady-state (CISS) sequencing clearly demonstrated a lumbosacral lipoma of caudal type, contiguous with the dermal sinus tract and not with the human tail. At 3 months old, the tail was surgically removed. The dermal sinus tract and contiguous lipoma were also resected, and untethering of the spinal cord was performed. Although both the human tail and CDS are frequently associated with spina bifida occulta, coexistence of the tail and CDS is exceedingly rare. CISS-MRI is useful for demonstrating the precise anatomical relationship between these complicated pathologies.