Cervical meningocele causing symptoms in adulthood: case report and review of the literature

[Congenital malformations of the brain misinterpreted as sequelae of poliomyelitis]

BACKGROUND

Poliomyelitis is an infectious disease of the peripheral motor neurons, which predominantly affects children and causes residual palsies. Because of the oral poliomyelitis vaccination started in Germany in 1960 and 1962 and the following rapid decline of the incidence of this infection, the postpolio syndrome in Germany is a disease of older people.

METHODS

Since 2008, we have offered a poliomyelitis outpatient consultation at the Center of Geriatrics, Protestant Hospital Göttingen-Weende and have treated 33 patients.

RESULTS

The spectrum of persistent deficits after poliomyelitis ranges from palsy of single extremities to severe disability with (temporary) ventilator dependence. Many patients suffer from scoliosis or shortening of limbs of different degrees, which promotes degenerative diseases of the spinal cord and joints with secondary myelopathy, injury of spinal nerve roots or peripheral nerves or respiratory failure. The postpolio syndrome is characterized by an increase of the functional deficits after decades of compensation. The palsies of 2 of the 33 patients were not caused by poliomyelitis but by myelomeningocele and schizencephaly, respectively.

CONCLUSION

The motor deficits acquired in childhood enable the majority of the patients to successfully master their lives. Because of the limited compensatory capacities of postpolio patients, even small increases in the severity of the palsy can cause a severe decline of the functional status and an impairment of the ability to live an independent life. In a substantial proportion of patients with the diagnosis poliomyelitis the symptoms are caused by other diseases.

Cervical myelomeningocele with CSF leakage: a case-based review

BACKGROUND

The cystic spinal dysraphism of the cervical and upper thoracic region (CDCT) accounts for only 3.9 to 8% of spina bifida cystica lesions. The presence of external cerebrospinal fluid (CSF) leakage is infrequent and very few authors have reported about surgical complications.

CASE REPORT

We present the case of a new born diagnosed of CDCT C1-C3 with a stalk of fibrovascular tissue, CSF leakage, hydrocephalus, and type Chiari II malformation, discuss about the chosen surgical technique and the associated complications, and make a review of the literature focusing on the main aspects of CDCT.

CONCLUSIONS

The CDCT with a stalk of neuroglial and/or fibrovascular tissue originates from the dorsal surface of the spinal cord and penetrates into a cervical cystic sac. The presence of CSF leakage, hydrocephalus, and/or type Chiari II malformation can influence to decide the most appropriate surgical technique.

Cystic Cervical Dysraphism: Experience of 12 Cases

Introduction:

Cystic spinal dysraphism of the cervical region is a relatively rare entity, which is more frequently associated with congenital anomalies such as split cord malformation, Chiari malformation, and corpus callosum agenesis, when compared to their lumbosacral counterpart. In our study, we have highlighted the clinical spectrum, associated anomalies (both neural and extra-neural), and surgical nuances of these.

Materials and Methods:

This study is a retrospective analysis of 225 patients from June 2010 to April 2017. Twelve patients who were between the age of 1 month and 16 years were included in our study. Average age was 32.6 months, and there were five female patients and seven male patients. All patients underwent neurological and radiological examinations followed by surgical excision of the sac and exploration of the intradural sac using the standard microsurgical technique. Neurological, Orthopedic and urological outcomes were studied in our description.

Results:

Of the 12 cases, 9 patients (75%) had some associated anomaly. Four of the 12 patients (25%) had split cord malformation, 3 had corpus callosum agenesis, and 5 had Chiari malformation. Patients with cervical spina bifida cystica (SBC) present with less neurologic deficits and greater association with CCA.

Conclusion:

The management strategy and association with other congenital anomalies separates cervical dysraphism as a different clinical entity rather than just group. These patients rather show favorable outcome with regard to neurologic, orthopedic, and urologic problems as compared to their caudal counterpart. Early surgical intervention even before the onset of symptoms is recommended. A proper radiological and urological evaluation is warranted.

Asymptomatic posterior cervical myelomeningocele with tethered cord in an adolescent: a rare form of spinal dysraphism with rare presentation

Unlike lumbar spinal dysraphism, cervical spinal dysraphism with or without tethered cord are rare lesions. These lesions are generally asymptomatic at birth, but with progression of time symptoms develop. These may be associated with various other anomalies. Not much have been reported in literature about cervical myelomeningocele (MMC) in adults or adolescents. We report a case of a 17 years old adolescent boy with cervical myelomeningocele with tethered cervical cord, who was completely intact neurologically even at this age and was without any associated anomaly. He came to us only for cosmetic reasons. The tethering band, which was evident on imaging was confirmed intra-operatively.

True Cervicothoracic Meningocele: A Rare and Benign Condition

Cervical meningoceles are rare spinal dysraphism, accounting for approximately 7% of all cystic spinal dysraphism. In spite of the rarity, the clinical course is most of the times benign. The surgical treatment includes resection of the lesion and untethering, when presented. We present a 14-day-old female child with true meningoceles who underwent to surgical excision and dura-mater repair. Retrospect analysis of the literature concerning true cervical meningocele is performed. By reporting this illustrative case, we focus on its classification and its differentiation from other types of cervical spinal dysraphism, such as myelocystocele and myelomeningocele. Although its course is benign, it is mandatory a continuum follow up with periodic magnetic resonance imaging of spinal cord, since late neurological deterioration has been described.

Missed limited dorsal myeloschisis: an unfortunate cause for recurrent tethered cord syndrome

AIM

This study aims to highlight the recurrent tethered cord syndrome in relation to the relatively new pathological entity of limited dorsal myeloschisis (LDM) and to mention the difficulties faced by the paediatric neurosurgeon in developing countries with reference to LDM which was not recognized at initial presentation.

MATERIALS AND METHODS

We present three cases of recurrent tethered cord syndrome who were operated early in life (not by paediatric neurosurgeons) as meningoceles and who were then subsequently referred to the senior author as they presented with clinical signs of re-tethering of the cord.

RESULTS

The first child of 1 year of age represented with cervicodorsal swelling 10 months after primary surgery for a cervical meningomyelocele done elsewhere on the second day of life. The second was a girl of 3 years of age who was operated at birth and presented with severe brachialgia and neck pain after 2 years. The third was a 19-year-old girl operated at birth presenting with spastic paraparesis and also hand weakness associated with kyphosis. All the three patients improved symptomatically and neurologically after redo surgery.

CONCLUSION

The diagnosis of LDMs, especially in developing countries, is frequently missed. This needs to be tackled and addressed so that children with this subset of neural tube defects, who otherwise would normally have a very good outcome, may not be blighted and left scarred for life at an early age.

Lumbosacral myelocystocele: A Case report

Myelocystocele is a rare variety of spinal dysraphism that presents as a skin covered, midline, lumbosacral mass. Many a time it is associated with other congenital anomalies but isolated myelocystocele is rarely associated with neurological deficit. MRI is the modality of choice for preoperative diagnosis. A 3 years old female child presented with skin covered lumbosacral mass since birth. There was no associated neurological deficit. MRI revealed single cyst, which was continuous with central canal of spinal cord. Peroperatively, myelocystocele was found with tethering of cord. Untethering of cord and repair of myelocystocele was performed with uneventful recovery.

Limited dorsal myeloschisis: a not-so-rare form of primary neurulation defect

PURPOSE

Limited dorsal myeloschisis (LDM) is a distinctive form of spinal dysraphism characterized by two constant features: a focal "closed" midline skin defect and a fibroneural stalk that links the skin lesion to the underlying cord. The embryogenesis is hypothesized to be incomplete disjunction between cutaneous and neural ectoderms, thus preventing complete midline skin closure and allowing persistence of a physical link (fibroneural stalk) between the disjunction site and the dorsal neural tube.

OBJECTIVE

We utilize the experience gained from the management of 63 patients with LDM to illustrate these features.

METHODS

All patients were studied with MRI or CT myelogram, operated on, and followed for a mean of 9.4 years.

RESULTS

There were 11 cervical, 16 thoracic, 8 thoracolumbar, and 28 lumbar lesions. Two main types of skin lesion were: saccular (26 patients; consisting of a skin base cerebrospinal fluid sac topped with squamous epithelial dome or a thin membranous sac) and nonsaccular (37 patients; with a flat or sunken squamous epithelial crater or pit). The internal structure of a saccular LDM could be a basal neural nodule, a stalk that inserts on the dome, or a segmental myelocystocoele. In nonsaccular LDMs, the fibroneural stalk has variable thickness and complexity. All fibroneural stalks contain glioneuronal tissues accompanied by variable quantities of nerves and mesodermal derivatives. In all LDMs, the fibroneural stalk was tethering the cord. Twenty-nine patients had neurological deficits. There was a positive correlation between neurological grade and age suggesting progression with chronicity. Treatment consisted of detaching the stalk from the cord. Most patients improved or remained stable. LDMs were associated with three other dysraphic malformations in more than coincidental frequencies: six LDMs were contiguous with dorsal lipomas, four LDMs shared the same tract or traveled in parallel with a dermal sinus tract, and seven LDMs were related to a split cord malformation. The embryogenetic implications of these associations are discussed.

CONCLUSION

LDM is a distinctive clinicopathological entity and a tethering lesion with characteristic external and internal features. We propose a new classification incorporating both saccular and flat lesions.

Cervical myelocystocele: Case report and review of literature

Dysraphisms involving cervical region are very rare and there are very few series describing their follow-up in literature. Here, we report a 6-year-old boy who underwent postnatal “cosmetic” repair of posterior cervical cystic lesion and presented to us with a large recurrence with syringohydromyelia and tethering. Tethered cord should be suspected in the presence of meningocele and intact neurology. Treatment protocols of such complicated cervical spinal dysraphisms should include intradural exploration and detethering, with an aim to prevent neurological deterioration in future.

Limited dorsal myeloschisis: a distinctive clinicopathological entity

BACKGROUND

Limited dorsal myeloschisis (LDM) is a distinctive form of spinal dysraphism characterized by 2 constant features: a focal "closed" midline defect and a fibroneural stalk that links the skin lesion to the underlying cord. The embryogenesis is hypothesized to be incomplete disjunction between cutaneous and neural ectoderms, thus preventing complete midline skin closure and allowing persistence of a physical link (fibroneural stalk) between the disjunction site and the dorsal neural tube.

OBJECTIVE

To illustrate these features in 51 LDM patients.

METHODS

All patients were studied with magnetic resonance imaging or computed tomography myelography, operated on, and followed for a mean of 7.4 years.

RESULTS

There were 10 cervical, 13 thoracic, 6 thoracolumbar and 22 lumbar lesions. Two main types of skin lesion were saccular (21 patients), consisting of a skin-base cerebrospinal fluid sac topped with a squamous epithelial dome, and nonsaccular (30 patients), with a flat or sunken squamous epithelial crater or pit. The internal structure of a saccular LDM could be a basal neural nodule, a stalk that inserts on the dome, or a segmental myelocystocele. In nonsaccular LDMs, the fibroneural stalk has variable thickness and complexity. In all LDMs, the fibroneural stalk was tethering the cord. Twenty-nine patients had neurological deficits. There was a positive correlation between neurological grade and age, suggesting progression with chronicity. Treatment consisted of detaching the stalk from the cord. Most patients improved or remained stable.

CONCLUSION

LDM is a distinctive clinicopathological entity and a tethering lesion with characteristic external and internal features. We propose a new classification incorporating both saccular and flat lesions.

Characteristics and surgery of cervical myelomeningocele

OBJECTIVE

Cervical myelomeningocele (CMMC) is a rare entity in neurosurgical practice, which presents different clinical characteristics compared with other more common lumbosacral variant. Since not much about this lesion has been reported in the literature, this study, herein, demonstrates by cases the clinical characteristics, methods, and techniques of surgical treatment of CMMC in children.

METHODS

A total of 10 children (six boys and four girls) with CMMC were recruited in this study. Their ages ranged from 9 days to 8 years with a median age of 3 months. All patients underwent neurological and radiological examinations. One was found to have had a mild unilateral arm weakness, and others were neurologically intact. Of these 10 patients, five had other associated neurological or orthopedic anomalies, including mild ventriculomegaly in two, cervical diastematomyelia in one, Chiari II malformation and hydrocephalus in one, and sacral spina bifida occulta in one. Surgical excision of the lesion with intradural exploration of the sac to release any potential adhesion bands was performed for all.

RESULTS

No complications, such as cerebrospinal fluid leakage and infection, had been found after operation. During the follow-up of 1-7 years (mean of 3.9 years), all cases did not suffer from aggravation of nervous symptoms. None of the patients deteriorated postoperatively, and the one with left arm weakness improved following surgery. In the two children with mild ventriculomegaly, cerebral ventricle returned to be normal after surgery.

CONCLUSIONS

The management strategies of CMMC are early surgical treatment with standard microneurosurgical techniques to prevent the development of neurological defects. It is safe and effective to adopt surgery excision of the lesions with intradural exploration of the sac to release any potential adhesion bands.

CERVICAL CONGENITAL MIDLINE MENINGOCELES IN ADULTS

OBJECTIVE

The clinical presentation, biomechanical evaluation, and surgical techniques for repairing cervical meningoceles in adulthood are presented. Cervical meningoceles are typically diagnosed in childhood and are rarely reported among spinal dysraphic lesions in adulthood. In most cases, the cervical spinal cord is found tethered to the dura and other soft tissues by fibrous or fibroneural elements. Cervical lesions, unlike those that arise more caudally, rarely leak cerebrospinal fluid.

METHODS

We report 5 male patients with meningoceles, aged 20 to 22 years (mean age, 20.4 years), in whom the primary evolution of the lesion occurred between 1999 and 2006.

RESULTS

All 5 patients presented to the hospital with cervical pain and mass. One patient had had a cerebrospinal fluid leak from the center of the lesion intermittently since birth. Another patient presented with neurological deficits and hypesthesia of the left hand. All patients underwent surgery. The lesion was excised, a partial laminectomy was performed, the internal tethering fibrous bands were released, and the neck of the structure was ligated. There was no neurological deterioration after surgery. No postoperative complications were observed during the 12-month follow-up period for each patient.

CONCLUSION

The goals of surgical exploration of these lesions are prevention of neurological deterioration, prevention of infection, and acceptable cosmetic outcome. Cervical meningoceles are tethering lesions of the spinal cord that may cause biomechanical injury with repetitive flexion-extension movements of the head and spine. It is therefore advisable to remove these lesions neurosurgically as soon as the diagnosis is made. Surgical intervention for cervical meningoceles should consist of exploration of the intradural fibrous bands with laminectomy, untethering of the spinal cord, and resection of the stalk and cyst of the meningocele.

Cervical myelomeningocele in adulthood: case report

OBJECTIVE

Cervical myelomeningocele is an extremely rare condition, accounting for only 1 to 5% of all neural tube defects. These lesions are usually diagnosed in childhood. Here, we report a case of a cervical myelomeningocele diagnosed and treated in adulthood.

CLINICAL PRESENTATION

A 52-year-old man presented with a 3-year history of progressing weakness and paresthesia in his upper limbs. Physical examination revealed a posterior midline neck mass covered with normal skin. Magnetic resonance imaging showed a soft-tissue mass tethering the cord by a stalk extending from the dorsal spinal cord to the dome of the lesion. Syrinx was evident cranially and caudally to the origin of the posterior stalk.

INTERVENTION

Surgical resection of the sac and intradural exploration were performed. The subdural space was explored, and the tethered structures were released. Histological examination showed small foci of meningothelial cells with psammoma bodies and rare thin fascicle of glial tissue dispersed in hyaline tissue. Immunohistochemical stains against glial fibrillary acidic protein and S100 confirmed the presence of bands of astrocytic tissue. The patient demonstrated early improvement of neurological deficits. Six months after surgery, he was asymptomatic and magnetic resonance imaging showed resolution of the syrinx.

CONCLUSION

We believe the syrinx in this patient was caused by a blockade of flow in the central canal and around the spinal cord as a result of the tethered cord. The untethering procedure resulted in the collapse of the syrinx followed by resolution of neurological deficits.

Giant true dorsal thoracic meningocele in a school-age child. Case report

A meningocele is a common form of spinal dysraphic lesions, but it is extremely uncommon in children in the upper thoracic region. The authors describe a rare case in which they found a giant true dorsal meningocele in the upper thoracic region in a symptomatic child, which, to their knowledge, is the first such reported case. A school-age child, who harbored a giant dorsal mass, complained of restriction of function. He underwent successful surgery in which the meningocele sac was totally removed.