Anomalous ependyma inducing split cord and meningomyelocele?

Myelo-meningocele: A multi-disciplinary problem

Background:

Myelo-meningoceles are part of congenital afflictions of the spinal column. They arise from the failure of the neural tube to fuse properly during early embryonic growth. The causes and sequalae are multiple and, therefore, require multiple disciplines, to handle them. This study assessed the role of inter-disciplinary approach in the management of myelo-meningoceles.

Materials and Methods:

From 1975 to 2007, the author repaired 20 midline lumbar and lumbo-sacral myelo-meningoceles; 5 in Jamaica and 15 in Nigeria. There were 11 males and 9 females. Their ages, at operation, ranged from 1 to 168 days. All had urine and faecal incontinence and severe paraparesis to paraplegia. Skeletal deformities were present in 16 cases. The operations were carried out under routine general anaesthesia and in prone position. All cases were followed-up for up to 60 months, apart from one who died 4 days at home after discharge.

Results:

There were no deaths within the period of hospitalisation, usually about 14 days. Those followed-up have not made much improvement, though they were able to sit up without support and move around by shifting on their buttocks on the floor.

Conclusion:

We must continue to help these patients, but under the umbrella of specialised rehabilitation centres with the different specialists working together to make these patients attain a meaningful life and be useful to themselves and the society.

Split cord malformation types I and II: a personal series of 131 patients

PURPOSE

A personal series of 131 patients with split cord malformation (SCM) operated on is presented.

METHODS

Age, gender, symptoms and signs, radiological and operative findings, complications, associated anomalies, outcome, and pathological specimens were analyzed.

RESULTS

There were 88 girls (73 %) and 43 boys (27 %). The female predominance was slightly more remarkable in type I SCMs than in type II SCMs. The presenting symptoms can be summarized as skin lesions, spina bifida aperta, scoliosis or kyphoscoliosis, sphincter disturbance, foot deformities and weakness, and/or atrophy in the lower extremities. The ages of patients with neurological deficits and orthopedic deformities were significantly older than those without deficits (P = 0.030). The duration of symptoms was longer in the patients with neurological deficits and orthopedic deformities than that in those without deficits (P = 0.00095). In six patients, composite SCMs were present. Only one patient with a type II SCM did not have an associated spinal cord lesion. A type I SCM was more frequently encountered in patients with spina bifida (P < 0.0005). Transient postoperative complications were seen in 29 patients (22 %). There was no permanent complication. Retethered cord syndrome developed in five patients with a type I SCM.

CONCLUSIONS

The risk of neurological and orthopedic deficits increases with the age of the patient. The risk of permanent deficit after surgery is very low. The whole spine must be examined for additional lesions. All patients should be surgically treated when diagnosed, especially before the development of orthopedic and neurological manifestations, and all associated lesions should also be treated at the same session.

Ventral tethering in split cord malformation

OBJECT

The author studied the specific issue of ventral tethering in cases of type II split cord malformation (SCM). He also discussed the issue of ventral tethering in patients with type I SCM in whom a bony septum and dural sleeve have been resected.

METHODS

Eleven (21%) of 52 patients with type II SCM were found to have a ventral fibrous septum tethering the hemicords to the ventral dura. Four categories of ventral septa were noted: 1) pure ventral intradural septa (three patients); 2) complete dorsoventral intradural septa (three patients); 3) dorsoventral septa continuous with a dermal sinus tract (two patients); and 4) ventral or complete septa continuous with ventral intestinal bands causing intestinal malrotation or diverticulum (three patients). Excluding one autopsy case, all 10 patients had symptoms or progressive neurological syndromes at diagnosis. Magnetic resonance imaging was completely ineffective, and computerized tomography (CT) myelography was only partially effective in detecting ventral tethering in 50% of cases. The only other positive predictor of ventral tethering is the association of dermal sinus tract and intestinal malformations. Combining this predictor with CT myelography, only 60% of the cases of ventral tethering could be suspected before surgery.

CONCLUSIONS

The author recommends examining all patients with type II SCM, and at surgery the ventral surface of the split length and reunion site should be thoroughly inspected to reveal a ventral band.