Spine ultrasounds should not be routinely performed for patients with simple sacral dimples

Diagnostic Utility of Spinal Ultrasounds in Neonates

OBJECTIVE

Ultrasound (US) is a common imaging modality used to evaluate spinal anomalies in newborns. However, many indications for the use of spinal US are associated with low diagnostic yield. The purpose of this study is to evaluate the indications and the diagnostic utility of spinal USs performed in newborns at our institution. We also review patient presentations for caudal regression syndrome (CRS) that was identified from the USs performed.

STUDY DESIGN

This study is a retrospective review of spinal USs performed between January 1, 2006, and December 31, 2021, in newborns at a single institution. Indications for each US and any associated abnormalities were noted. Infants with abnormal USs showing CRS are described with their long-term medical outcomes.

RESULTS

A total of 592 USs were performed during the specified time period of which 72 (12%) were abnormal. The presence of a sacral dimple was the most common indication for performing a spinal US, although only 14 (4%) were identified as abnormal. Of these 14, 6 (43%) were further evaluated by spinal magnetic resonance imaging (MRI) at the recommendations of a pediatric radiologist and of these, only 2 (14%) had abnormal MRI findings. The two newborns with abnormal MRI findings had mothers with diabetes mellitus in their pregnancies. Of note, one additional newborn had abnormalities on spinal US that was never confirmed on MRI due to being lost to follow-up. Among the other indications, anorectal anomalies (odds ratio [OR], 7.55; 95% confidence interval [CI], 3.01-18.91), spinal mass (OR, 17.99; 95% CI, 7.86-41.2), and meningocele were most associated with abnormal findings.

CONCLUSION

Overall, spinal US has a low diagnostic yield. Sacral dimple was the most common indication for performing a spinal US but had a low yield with few long-term sequelae. Anorectal anomalies had a strong association with abnormal US findings.

KEY POINTS

· Sacral dimple is a common indication for spinal ultrasound.. · Spinal ultrasound has low diagnostic yield when performed for sacral dimple.. · Caudal regression syndrome is associated with maternal diabetes and numerous long-term comorbidities..

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Meningitis due to Enterobacter aerogenes in the community associated with congenital dermal sinus in a Japanese infant

Congenital dermal sinus is associated with meningitis caused by atypical pathogens. Although nosocomial infections with Enterobacter aerogenes in limited settings have been reported, community-acquired infections associated with congenital dermal sinus are rarely observed. We present the first non-neonatal case of a 3-month-old boy with meningitis due to Enterobacter aerogenes associated with congenital dermal sinus. The patient visited our hospital with fever and a skin dimple with lumbosacral hemangioma. He was diagnosed with meningitis based on cerebrospinal fluid (CSF) examination, which showed a cell count of 5717/µL. Subsequently, antimicrobial therapy with meropenem, cefotaxime (CTX), and vancomycin was initiated. His fever subsided, and the number of CSF cells decreased. Magnetic resonance imaging was performed for the dimple of the lumbosacral region, revealing the congenital dermal sinus. Enterobacter aerogenes was isolated from CSF and stool cultures, and treatment was adjusted to CTX alone based on susceptibility testing. However, the CSF culture remained positive. Although CTX was effective, the response to treatment was partial, and a switch to meropenem was required to achieve negative CSF cultures. In conclusion, Enterobacter aerogenes, although atypical, can cause community-acquired meningitis associated with congenital dermal sinus. Consistent with previous reports, in this case, a hemangioma on the back led to the diagnosis of congenital dermal sinus. Hence, systemic examination, including the back, is important. In addition, use of a third-generation cephalosporin (e.g., CTX) may not negate the CSF culture, even if it is effective. Thus, a switch to another drug (e.g., carbapenem) may be required.

Ultrasound of congenital spine anomalies

Ultrasonography (US) is the first-line imaging modality for screening neonates and young infants with suspected spinal abnormalities. Whether performed for a suspicious congenital skin lesion, such as a lumbosacral tract or lipomatous mass, or abnormal neurological findings, US can help define spinal anatomy, characterize congenital spine malformations, and direct further work-up and management. The purpose of this article is to review the diagnostic imaging approach to infant spine US, including technique and indications, normal anatomy and variants with a focus on embryological origins, and classification and diagnosis of congenital spine malformations.

Cutaneous Stigmata of the Spine: A Review of Indications for Imaging and Referral

Cutaneous stigmata of the midline spine are a common question in pediatrics. They are known to be related to a higher likelihood of underlying dysraphic spinal abnormalities. Clear understanding of different types of cutaneous stigmata and correlating dysraphic findings can aid in appropriate imaging workup and timely management of patient pathology. In this article, the authors review midline spinal cutaneous findings in the pediatric population with occult spinal dysraphism.

Neonatal Dermatology: The Normal, the Common, and the Serious

The objective of this review is to help practitioners of neonatal and pediatric medicine become more familiar with diagnosing and managing neonatal skin conditions. This article will discuss normal neonatal skin care and benign and common rashes, as well as some of the serious dermatologic conditions that require specialists for further evaluation and/or treatment.

Clarifying Misleading Lumps and Sinuses in the Newborn

Neonates often have congenital lumps or sinuses. It is expected that pediatricians will distinguish those with important physiologic implications from those without. Accurate understanding of these lesions is important for the practitioner to avoid unnecessary tests and anxiety and to ensure that seemingly benign lesions with important implications are addressed in a timely manner. This review aims to clarify the consequences of some lesions that can easily be misinterpreted, offering guidance in the initial management of patients with congenital lumps or sinuses. We address several lesions that can easily be misconstrued, including wattles, preauricular lesions, sacral sinuses, second branchial cleft anomalies, torticollis, and dermoid cysts.

Variation in Management of Cutaneous Lumbosacral Findings in Newborns

BACKGROUND

Cutaneous lumbosacral findings in neonates are common in the newborn nursery but may also be associated with occult spinal dysraphism. Variation in management of lumbosacral findings by neonatal clinicians has not been previously described.

METHODS

Clinicians in the Better Outcomes through Research for Newborns (BORN) Network were invited to participate in an electronic survey. Participants reviewed 18 photographs of lumbosacral findings in asymptomatic neonates and selected 1 or more initial management step(s): routine care, watchful waiting, imaging, and/or subspecialty consultation. Additional data collected include ease of access to imaging and subspecialty consultants and characteristics of respondents.

RESULTS

Of 407 BORN Network clinicians, 206 (51%) completed the survey. Respondents were in >90% agreement in initial management approach of 8 of 18 cases. The most common initial actions were spinal ultrasound (53%), neurosurgery evaluation (18%), and MRI (13%). Anomalies of the gluteal crease had the lowest proportion of agreement. In 2 cases, there were differences in respondents' choice to image or consult a subspecialist depending on their percent clinical full time equivalent spent taking care of neonates <1 month of age: (1) coccygeal hair (P = .02) and (2) deviated gluteal crease (P = .02).

CONCLUSIONS

Variation in initial management of neonatal lumbosacral findings by clinicians in the BORN Network was seen most often for deviations of the gluteal crease, flat vascular macules, and coccygeal hair.

A Review of Benign Congenital Anomalies

Benign congenital anomalies are common in neonates. Some of these common benign congenital anomalies include preauricular pits, sacral dimples, supernumerary digits, accessory nipple, and natal teeth. It is important for health care providers who take care of newborns to recognize these benign anomalies so that unnecessary evaluations and investigations are not performed. However, some of these anomalies may be associated with clinically significant conditions. In this article, we discuss when further evaluation should be performed in babies presenting with these common benign congenital anomalies. [Pediatr Ann. 2020;49(2):e66-e70.].

Importance of Physical Examination and Imaging in the Detection of Tethered Cord Syndrome

Tethered cord syndrome (TCS) is a type of occult spinal dysraphism that may lead to permanent neurologic and orthopedic deficits. Infants with TCS may have lumbosacral cutaneous malformations (LsCMs). We studied 67 infants referred to a single pediatric urology practice for a urological concern unrelated to occult spinal dysraphism with no prior diagnosis of LsCM between March 1, 2015 and September 30, 2018. Each infant underwent a spinal ultrasound. If an abnormality was detected, they were referred to a pediatric neurosurgeon. The most common cutaneous manifestations were duplicated or bifurcated (46%) gluteal folds and gluteal asymmetry (16%). Fourteen (21%) of the 67 patients had an abnormal spinal ultrasound; 5 of the 14 infants underwent a lumbar magnetic resonance imaging. One infant had urodynamics studies and a tethered cord release. Pediatricians should be familiar with TCS and perform lumbar physical examinations for LsCMs suggestive of TCS to ensure prompt diagnosis and management and avoid potentially devastating complications.

Optimal Timing of Spinal Ultrasound Evaluations for Sacral Dimples in Neonates: Earlier May Not Be Better

OBJECTIVES

A spinal ultrasound (US) evaluation during the immediate postnatal period may have limited ability in evaluating filum thickness because of the spinal cord pulsation caused by a crowded subarachnoid space and the cerebrospinal fluid deficiency during this period. This study aimed to determine the optimal timing of spinal US to evaluate sacral dimples in neonates.

METHODS

This study included 585 neonates who had a clinically suspicious sacral dimple and underwent spinal US examinations between January 2015 and August 2017. Patients were classified into 1 of 2 groups based on whether measurements of all parameters were possible (group A) or not (group B). Neonatal and maternal clinical factors, including the antenatal history and US parameters, were compared between groups.

RESULTS

Group A included 443 patients, and group B included 82. Patients in group B were significantly younger (6.2 versus 31.0 days), had a younger corrective age (38.9 versus 42.5 weeks), and had a smaller body weight (3.1 versus 4.6 kg) than those in group A (all P < .005). However, no statistically significant differences were found in other patient or maternal factors (P > .05 for all). The pulsation of the conus medullaris and nerve roots of the cauda equina (14.6% versus 100%), thickening and echogenicity of the filum terminale (2.4% versus 100%), and the presence of a normal subarachnoid space (18.3% versus 100%) were significantly more difficult to detect in group B than in group A (all P < .001).

CONCLUSIONS

For an accurate evaluation, which can reduce unnecessary confusion and costs, spinal US can be delayed until neonates grow beyond 31 days, with a corrected age of older than 42.5 weeks and body weight of greater than 4.6 kg.

Dorsal midline cutaneous stigmata associated with occult spinal dysraphism in pediatric patients

PURPOSE

To investigate the prevalence of occult spinal dysraphism (OSD) and subsequent neurosurgery in pediatric patients with isolated or combined dorsal midline cutaneous stigmata with or without other congenital malformations.

METHODS

We carried out a retrospective review of patients who underwent sonography or magnetic resonance imaging (MRI) for OSD because of suspicion of dorsal midline cutaneous stigmata (presumed to be a marker for OSD) between January 2012 and June 2017. Information about patient characteristics, physical examination findings, spinal ultrasound and MRI results, neurosurgical notes, and accompanying congenital anomalies was collected.

RESULTS

Totally 250 patients (249 ultrasound and one MRI screening) were enrolled for analysis. Eleven patients underwent secondary MRI examinations. The prevalence of OSD confirmed by an MRI was 2.4% (6 patients including one MRI screening). Five patients (2%) had tethered cord and underwent prophylactic neurosurgery, 3 of whom had a sacrococcygeal dimple and a fibrofatty mass. Prevalence of tethered cord increased as markers associated with a sacrococcygeal dimple increased (0.5% of the isolated marker group, 8.1% of the 2-marker group, and 50% of the 3-marker group). Incidence of OSD with surgical detethering in 17 other congenital anomaly patients was 11.8%, which was higher than the 1.3% in 233 patients without other congenital anomalies.

CONCLUSION

Our results suggest that the presence of dorsal midline cutaneous stigmata, particularly fibrofatty masses, along with a sacrococcygeal dimple is associated with OSD or cord tethering requiring surgery. OSD should be suspected in patients with concurrent occurrence of other congenital anomalies.

Outcome of ultrasonographic imaging in infants with sacral dimple

Purpose

Sacral dimples are a common cutaneous anomaly in infants. Spine ultrasonography (USG) is an effective and safe screening tool for patients with a sacral dimple. The aim of this study was to determine the clinical manifestations in patients with an isolated sacral dimple and to review the management of spinal cord abnormalities identified with USG.

Methods

We reviewed clinical records and collected data on admissions for a sacral dimple from March 2014 through February 2017 that were evaluated with spine USG by a pediatric radiologist. During the same period, patients who were admitted for other complaints, but were found to have a sacral dimple were also included.

Results

This study included 230 infants under 6-months-old (130 males and 100 females; mean age 52.8±42.6 days). Thirty-one infants with a sacral dimple had an echogenic filum terminale, and 57 children had a filar cyst. Twenty-seven patients had a low-lying spinal cord, and only one patient was suspected of having a tethered cord. Follow-up spine USG was performed in 28 patients, which showed normalization or insignificant change.

Conclusion

In this study, all but one infant with a sacral dimple had benign imaging findings. USG can be recommended in infants with a sacral dimple for its convenience and safety.

Sonographic spinal imaging of normal anatomy, pathology and magnetic growing rods in children

The wide availability of ultrasound, along with its lack of ionizing radiation burden and need for sedation for most exams, often make sonography the first line in the imaging evaluation of children. The developing osseous anatomy of the spine in young infants provides a distinct window allowing for a detailed depiction of the spinal canal and its contents, which is not present in older children or adults. Here we review the clinical indications, sonographic technique, normal anatomy and pathology for imaging the lumbosacral spine in neonates and young infants. Additionally, we review the procedure for ultrasound assessment of the lengthening of magnetically controlled growing spinal rods, which allows orthopedists and radiologists to evaluate the effectiveness of distraction procedures of this hardware without the use of ionizing radiation.