Surgery for spina bifida occulta: spinal lipoma and tethered spinal cord

The technical evolution of the surgery for spina bifida occulta (SBO) over the course of a half-century was reviewed with special foci placed on the spinal lipoma and tethered spinal cord. Looking back through history, SBO had been included in spina bifida (SB). Since the first surgery for spinal lipoma in the mid-nineteenth century, SBO has come to be recognized as an independent pathology in the early twentieth century. A half-century ago, the only option available for SB diagnosis was the plain X-ray, and pioneers of the time persevered in the field of surgery. The classification of spinal lipoma was first described in the early 1970s, and the concept of tethered spinal cord (TSC) was proposed in 1976. Surgical management of spinal lipoma with partial resection was the most widely practiced approach and was indicated only for symptomatic patients. After understanding TSC and tethered cord syndrome (TCS), more aggressive approaches became preferred. A PubMed search suggested that there was a dramatic increase of publications on the topic beginning around 1980. There have been immense academic achievements and technical evolutions since then. From the authors' viewpoint, landmark achievements in this field are listed as follows: (1) establishment of the concept of TSC and the understanding of TCS; (2) unraveling the process of secondary and junctional neurulation; (3) introduction of modern intraoperative neurophysiological mapping and monitoring (IONM) for surgery of spinal lipomas, especially the introduction of bulbocavernosus reflex (BCR) monitoring; (4) introduction of radical resection as a surgical technique; and (5) proposal of a new classification system of spinal lipomas based on embryonic stage. Understanding the embryonic background seems critical because different embryonic stages bring different clinical features and of course different spinal lipomas. Surgical indications and selection of surgical technique should be judged based on the background embryonic stage of the spinal lipoma. As time flows forward, technology continues to advance. Further accumulation of clinical experience and research will open the new horizon in the management of spinal lipomas and other SBO in the next half-century.

The Necessity of Dural Resection for Nasal Dermal Sinus Cyst With Intracranial Extension

Nasal dermal sinus cysts are characterized by an intracranial-extradural extension. Complete extirpation of nasofrontal dermoid sinus cysts is essential for effective treatment to minimize recurrence. The authors revealed the pathologic findings of the cranial end connected to the dura. In our case, the cranial end and dura were fibrous connective tissues that were difficult to separate. For complete extirpation of the nasal dermal sinus cyst with intracranial extension, the cranial ends of the nasofrontal dermoid sinus cyst and dura should be resected en bloc.

[Clinical analysis of 59 cases of pediatric nasal dermal sinus cysts with midfacial infection as the first symptom]

Objective:To review the clinical and radiological presentation and management of infected nasal dermal sinus cysts（NDSC） in children. Methods:Clinical data were collected from 59 NDSC children with secondary fronto-orbital area infection who presented to Beijing Children's Hospital from January 2007 to December 2021. All patients underwent preoperative imaging workup, including MRI and CT. All patients underwent endoscopic excision of a NDSC under general anesthesia. Results:A total of 59 patients were included in the study,while 58 presented with a sinus, 1 presented with a cyst.The main lesions of NDSC included nasal root in 20 cases （33.9%）, nasal bridge in 34 cases （57.6%）, nasal tip in 4 cases （6.8%）, and nasal tip and nasal root in 1 case （1.7%）. The depth of lesions included 6 cases （10.2%） of superficial type of nasal frontal bone, 33 cases （55.9%） of nasal frontal bone, 19 cases （32.2%） of intracranial epidural type, and 1 case （1.7%） of intracranial epidural type. The main sites of infection included inner canthus in 15 cases （25.4%）, nasal dorsum in 22 cases （37.3%）, nasal root in 16 cases （27.1%）, and forehead in 6 cases （10.2%）. Among 59 cases, 7 cases （11.9%） were complicated with other diseases, and 4 cases（6.8%） had external nasal deformities. Surgical approaches included transverse incision in 12 cases（20.3%）, minimal midline vertical incision in 41 cases （69.5%）, external rhinoplasty in 4 cases （6.8%） and bicoronal incision with vertical incision in 2 cases （3.4%）. The range of lesions was completely consistent with MRI results.All cases were successfully operated without one-stage nasal dorsum reconstruction. All patients were followed up from 7 to 173 months（average 52.2 months）. There were 6 cases of recurrence, all of which were in situ recurrence. The operation was performed again, and no recurrence has occurred since the follow-up, No nasal deformity was noted, and cosmetic outcome were favorable for all patients. Conclusion:NDSC infection in children with midfacial infection as the first symptom is rare in clinical practice, and its manifestations are diverse. Early diagnosis and rational treatment are very important to improve the cure rate.Preoperative high resolution MRI combined with CT scanning is of great significance in judging the course of NDSC, especially the intracranial extension. The treatment goal is to achieve minimally invasive and individualized treatment under the premise of complete excision of the lesion, and take into account the cosmetic needs.

Dermoid sinus type VI associated with spina bifida and tethered cord syndrome in a French Bulldog

A 4-mo-old French bulldog was presented with acute onset pain and reluctance to move. A tubular structure arising in the dorsal thoracic midline and extending from a cutaneous orifice into deeper tissues was palpated on physical examination. Computed tomography with sinography revealed a dermoid sinus associated with spina bifida at the level of T3-T4. On surgical exploration, the dermoid sinus was found to communicate with the dura. Histology confirmed the diagnosis and classification as a type VI dermoid sinus. The pain response and hyperesthesia were suspected to be the result of tethered cord syndrome. Complete resolution of clinical signs was appreciated post-surgery, with the patient still free of clinical signs 3 mo later.

Double dermal sinus tracts of the cervical and thoracic regions: a case in a 3-year-old child and review of the literature

INTRODUCTION

Dermal sinus tracts are rare congenital abnormalities characterized by an epithelium-lined tract that extends from the subcutaneous tissue to the underlying thecal sac or neural tube. These developmental anomalies can present asymptomatically with a cutaneous dimple or with devastating complications including recurrent episodes of meningitis, or neurological complications including paralysis. Dermal sinus tracts generally occur as single lesions, and the presentation of midline double dermal sinus tracts of the cervical and thoracic regions has not been previously described.

METHODS

Here, we present the case of a 3-year-old girl suffering from recurrent episodes of myelitis, paraparesis, and intramedullary intradural masses, who was diagnosed with double dermal sinus tracts of the cervical and thoracic regions. We also present a summary of all previous reported cases of multiple dermal sinus tracts.

RESULTS

Our patient was successfully treated surgically and is now 2 years status post her last procedure with a significant improvement in her neurologic function and normal muscle strength and tone for her age, and there was no recurrence of her symptoms.

CONCLUSIONS

Early treatment with prophylactic surgery should be performed when possible, but removal of these lesions once symptoms have arisen can also lead to success, as in the case presented here. Complete excision and intradural exploration is required to excise the complete tract.

Spina bifida occulta and aperta: a review of current treatment paradigms

Spina bifida remains a challenging neurosurgical entity to manage despite both an increased awareness of the disease as well as a decreased incidence due to folic acid supplementation. We review the spectrum of neural tube defects, which are the second most common serious congenital defect and the most common of the central nervous system, and discuss the latest management paradigms. The challenges of timely diagnosis and treatment of spina bifida occulta and the latest advances in fetal repair of spina bifida aperta (myelomeningocele) will be discussed. The authors review the literature and share their experience with managing neural tube defects.

Dermal Sinus Tract of the Thoracic Spine Presenting with Intramedullary Abscess and Cranial Nerve Deficits

Congenital dermal sinus tract of the spine is an unusual developmental defect which represents a failure of the surface ectoderm and dermal elements to separate from the neuroectoderm. A 15-month-old female presented with high fever, severe right hemiparesis, difficulty breathing and cranial nerve deficits. Magnetic resonance imaging (MRI) of the spine revealed a congenital dermal sinus tract at the Th6 level, an intramedullary collection extending up to the brainstem and a probable intramedullary cystic lesion. The child was operated acutely with ligation of the sinus tract, drainage of the abscess and partial removal of the intramedullary lesion. Due to abscess recurrence, she was reoperated with complete excision of the dermal sinus tract, abscess redrainage and subtotal excision of the dermoid cyst (retaining a part of its capsule). Pus culture isolated Corynebacterium species and Peptococcus species and histology of the lesion showed a dermoid cyst. Postoperatively, after an initial neurologic deterioration, she progressively improved. An MRI scan at 15 months neither showed recurrence of the collection nor regrowth of the lesion. Spinal dermal sinus tracts that remain unnoticed or untreated can result in serious complications and should be operated as soon as possible to prevent undesirable sequelae.

A rare case of split pons with double encephalocoele, dermal sinus tract, and lipomeningomyelocele: a case report and review of literature

INTRODUCTION

Multiple neural tube defects and pontine anomalies are relatively rare. Cases of split pons and double encephalocoeles in combination with other spinal anomalies are even rarer.

CASE REPORT

Here, we present a very rare case of split pons, twin encephalocoeles (one of which was atretic), lumbar dermal sinus tract, lumbosacral lipomeningomyelocele, thickened filum, and syringomyelia that was managed successfully at our institute.

CONCLUSION

Cases of split pons and double encephalocoeles in combination with other spinal anomalies are very rare, and to the best of author's knowledge, this is the first case report of these multiple anomalies in world literature.

Spina bifida occulta in high grade spondylolisthesis

A 14-year-old boy presented with symptomatic high-grade dysplastic type spondylolisthesis, with a presence of spina bifida occulta, not diagnosed by plain radiographs, but confirmed on preoperative CT and MR. Circumferential fusion with partial reduction of L5/S1 was performed. Awareness of the coexistence of spondylolisthesis and spina bifida by an accurate preoperative planning is paramount to avoid iatrogenic damage to neural elements during surgery.

Section of the filum terminale: is it worthwhile in Chiari type I malformation?

A section of the filum terminale (SFT) is used for the surgical treatment of isolated tethered cord or that resulting from neurulation disorders. More recently, it has been proposed for the management of the occult tethered cord syndrome (OTCS), though it is still under debate. Even more controversial appears to be the use of SFT in patients with Chiari type I malformation (CIM), which is based on the possible presence of OTCS. This review shows that: (1) there are issues both in favor and against the occurrence of OTCS, (2) there is no significant correlation between CIM and tethered cord, the old "caudal traction theory" being not supported by clinical or experimental evidences. On these grounds, a relationship between CIM and OTCS is hard to be demonstrated, (3) a subgroup of patients with CIM suffering from OTCS may exist and benefit from SFT.

Congenital dermal sinus of the cervical spine: clinical characteristics and management

Congenital dermal sinus (CDS) in the cervical region is extremely rare with only few cases reported in the literature. This study reports a young case of CDS, by which we demonstrate the clinical characteristics and management of cervical CDS, particularly in kids. A 2-year and 7-month-old male child who presented with a one-year history of difficulty in holding objects by hands was diagnosed to have harbored a CDS in the cervical spine since birth. Neurological examination demonstrated mild weakness in both hands and also atrophy in intrinsic hand muscles. Surgery was performed right after diagnosis. Intraoperatively, the sinus tract was totally excised, and untethering was performed. No complications were found after operation. Histopathological examination suggested dorsal dermal sinus. During the follow-up of three years, the patient presented a stable neurologic deficit but did not suffer from an aggravation or improvement of nervous symptoms. At three-year follow-up, the patient was a stable neurologic deficit, and MRI revealed no evidence of the untethered cervical spinal cord and dermal sinus tract. The management strategies of CDS are early surgical treatment to prevent the development of neurological defects.

Infected spinal dermal sinus tract with meningitis: a case report

PURPOSE

Congenital dermal sinus tract (DST), an uncommon entity of cranial or spinal dysraphism, occurs along the midline neuraxis that may arise from nasion and occiput down to the lumbar and sacral region. It is often diagnosed in infants and children for skin signs, neurological deficits, local infection, meningitis, or abscess. For spinal DST, there is a paucity of case or series report in Taiwan.

CASE REPORT

In this paper, we report a case in a 6-year-old girl. The girl presented with midline lumbar skin dimple, hypertrichosis, and history of bacterial meningitis. She was successful treated by surgical excision of the DST with local infection that ended within the subarachnoid space between L2-3 vertebrae.

CONCLUSION

This case highlights the importance of a thorough examination of the midline craniospinal axis in children with meningitis or history of meningitis.

Diastematomyelia - a diagnostic and therapeutic problem. Case study

BACKGROUND

Diastematomyelia is a type of dysraphism with a double or bifid spinal cord divided by an osseous septum. This defect often co-occurs with other developmental disorders of the skull or the atlanto-occipital junction. The course may be benign or aggressive. 2.

CASE REPORTS

We describe two female patients treated in the Rehabilitation Clinic and the Orthopaedic Department at the Medical University of Lublin in the years 2004 - 2009. The first patient was diagnosed at the age of 20 years to have diastematomyelia at the L3 level and spina bifida occulta at L1- S5 and at the C1 arch. In the other patient, diastematomyelia at the L3 level and spondylolisthesis at L5-S1 were found at the age of 14 years. Initially both patients were treated for lumbosacral radicular syndromes. Physiotherapy intensified the pain. The patient with diastematomyelia and L5-S1 spondylolisthesis had L5-S1 segment stabilization performed at the age of 16. The pain subsided after the surgery. The other patient was instructed to stop rehabilitation, follow a balanced lifestyle, and refrain from physical work, which eliminated the pain.

DISCUSSION

Managing a patient with diastematomyelia demands caution. Diagnosis of this defect requires a thorough cause-and-effect analysis of the presenting signs and symptoms of spinal dysfunction. The treatment should be dependent on local pain intensity (which is often not directly associated with the disorder) and on the degree of neurological dysfunction. 5.

CONCLUSIONS

1. A thorough clinical evaluation with spinal imaging prior to elective surgery for scoliosis and other spine deformities should be a standard procedure undertaken in order to avoid complications. 2. The treatment for diastematomyelia should depend on the intensity of local pain and on the level of neurological dysfunction. 3. Broadly understood rehabilitation is not always effective, often increasing the pain and/or neurological complaints.

Dermal sinus tract of the spine

OBJECTIVE

Spinal dermal sinus tract (DST) is a rare entity which usually comes to clinical attention by cutaneous abnormalities, neurologic deficit, and/or infection. We performed this study to assess presentation patterns, associated anomalies, radiologic, urologic, and surgical findings in children afflicted with spinal DST.

METHODS

Medical records of 35 children treated for spinal DST in Children's Medical Center from January 2001 to December 2008 were reviewed.

RESULTS

Patients' age ranged from 3 days to 8.44 years. Dermal sinuses were located most frequently in the lumbar and lumbosacral regions. The most common causes for referral were abnormal skin findings (57.1%) and infection (31.4%). Notably eight patients presented with meningitis. The overall rate of neurologic abnormalities was 37.1%, four of whom presented acutely with rapidly progressive paraplegia and meningitis. The most common magnetic resonance imaging finding was tethered cord (63%). At least one urological evaluation was performed in 30 patients, which revealed abnormal results in 77% of them. All patients underwent complete resection of the tract and repair of associated abnormalities. Most tracts terminated within the intradural space. Fifteen patients (42.8%) had inclusion tumor with the dermoid tumor being the most common. None of the patients demonstrated neurological deterioration postoperatively.

CONCLUSION

Dermal sinus tract is an innocuous-appearing spinal dysraphism that may contribute to devastating morbidities if not timely addressed. In order to prevent complications, timely surgical intervention including complete resection of sinus tract with intradural exploration and correction of associated abnormalities is of utmost importance.

Outcome of untethering for symptomatic spina bifida occulta with lumbosacral spinal cord tethering in 31 patients: analysis of preoperative prognostic factors

BACKGROUND CONTEXT

The most important goal for treating symptomatic lumbosacral spinal cord tethering is early untethering.

PURPOSE

To investigate preoperative symptoms that may have affected the outcome.

STUDY DESIGN

Patients with or without improvement and with or without favorable outcome after untethering were compared retrospectively by chart and image review.

PATIENT SAMPLE

Thirty-one patients (age between 2 days to 25 years) with spina bifida occulta and symptomatic cord tethering were analyzed. Presenting symptoms (neurological deficits, urological dysfunction, and lower limb deformities) were assessed before and after untethering.

OUTCOME MEASURES

Favorable outcome was defined as complete relief of symptoms or mild symptoms whereby patients are able to look after their own personal care without assistance. Unfavorable outcome was defined as moderate or severe disability whereby patients are unable to attend to their own bodily needs without assistance, are bedridden, or require constant nursing attention.

METHODS

Differences in patient characteristics and presenting symptoms were compared between those with and without clinical improvement and favorable outcome. Multivariate logistic regression was used to identify prognostic factors affecting the outcome.

RESULTS

The average age at surgery was 7.2 years, with a male-to-female ratio of 1.2. The average follow-up time was 4 years. At least one of the following symptoms was present in all patients: neurological deficits (83.9%), urological dysfunction (77.4%), or limb deformities (38.7%). After untethering, all patients had either symptoms stabilized (14 patients, 45.2%) or improved (17 patients, 54.8%), and 14 patients (45.2%) achieved total resolving of symptoms. Logistic regression confirmed that younger age (< or =2 years, odds ratio [OR] 22.0, p=.026), lipomas of filum terminale (OR 25.6, p=.042), and a poor anal tone (OR 10.4, p=.061) were positive prognostic factors for the improvement in symptoms. The functional outcome was determined by the age at surgery (OR 0.9 per year since 1 year old, p=.04) and the presence of limb deformities (OR 0.06, p=.017).

CONCLUSIONS

In conclusion, our study suggests that untethering should be performed immediately once the patient shows evidence of symptomatic lumbosacral cord tethering, irrespective of age. Untethering can interrupt progression of symptoms, but sphincter dysfunction and muscle weakness are more likely to improve or resolve. Benefits can be seen in all patients, but young children (before 2 years old) have a higher chance to gain favorable outcome. Retethering is a main concern during follow-up, particularly for the more complicated lipomyelomeningoceles. Investigations using electrophysiologic and urodynamic studies are helpful for early detection of subtle symptomatic cord tethering or retethering.

[Intramedullary abscess of spinal cord as a complication of existing dermal sinus]

The paper describes a rare case of intramedullary spinal cord abscess in an infant after dermal sinus. In discussion with literature review the contemporary approach to patients with this pathology is highlighted.

Congenital pterional dermal sinus in an 18-month-old child: case report

OBJECTIVE

Congenital dermal sinus tracts most frequently occur in the midline and are often associated with dermoid or epidermoid inclusion cysts. A lateral cranial origin is extremely rare and anatomically inconsistent with an etiology involving closure of the rostral neural tube during embryogenesis.

CLINICAL PRESENTATION

We describe the first case of a pterional cranial dermal sinus tract associated with a small epidermoid, with extension to the dura of the anterior cranial fossa.

INTERVENTION

The extra- and intracranial portions of the tract were visualized and resected with the use of an operating microscope. Pathological diagnosis confirmed dermal sinus tract.

CONCLUSION

We review the existing literature and address the developmental and clinical features pertinent to the management of cranial dermal sinus tracts, emphasizing the need for exploration of these potentially harmful lesions.

Tethering tracts in spina bifida occulta: revisiting an established nomenclature

OBJECT

The goal of the present study goal was to systematically confirm the previously recognized nomenclature for tethering tracts that are part of the spectrum of occult spinal dysraphic lesions.

METHODS

The tethering tract in 20 patients with spina bifida occulta underwent histological examination with H & E staining and epithelial membrane antigen (EMA) immunolabeling, and additional selected specimens were stained with Masson trichrome.

RESULTS

All tethering tracts contained fibrous connective tissue. Four tracts were lined with epithelial cells and either originated within a dermoid cyst, terminated at a skin dimple/sinus opening, or had both of these characteristics. No tethering tracts exhibited EMA positivity or meningeal elements. Although all tethering tracts originated in juxtaposition to the spinal cord, their termination sites were variable.

CONCLUSIONS

Based on histological findings and presumed embryological origin, the authors broadly classified tethering tracts terminating within the dura mater, epidural space, or lamina as "short tethering tracts" (STTs). The STTs occurred mostly in conjunction with split cord malformations and had a purely fibrous composition. Tethering tracts terminating superficial to the overlying lamina were classified as "long tethering tracts" (LTTs), and the authors propose that these are embryologically distinct from STTs. The LTTs were of two varieties: epithelial and nonepithelial, the former being typically associated with a skin dimple or spinal cord (epi)dermoid cyst. In fact, analysis of the data suggested that not every tethering tract terminating in or on the skin should be classified as a dermal sinus tract without histological confirmation, and because no evidence of meningeal tissue-lined tracts was detected, the use of the term "meningocele manqué" may not be appropriate.

Clinical Urological Outcomes Following Primary Tethered Cord Release in Children Younger Than 3 Years

PURPOSE

Current practice at our institution is to recommend tethered cord release at diagnosis to prevent the onset or worsening of symptoms. Tethered cord release is frequently performed in children younger than 3 years who often have no urological manifestations. To our knowledge there are currently no long-term data on urological outcomes in this age group.

MATERIALS AND METHODS

We completed a retrospective review of 475 cases of tethered cord release performed at a single institution between 1995 and 2002. Of these surgeries 173 were performed in children younger than 3 years. Clinical outcomes, and preoperative and postoperative urodynamic and radiographic studies were evaluated.

RESULTS

A total of 79 patients met study criteria. Average age at surgery was 9.6 months and average followup was 5.2 years (range 6 months to 11.2 years). At followup 49 patients (62.1%) had no urological complaints and 30 (38%) had urological problems. A total of 20 children (25.3%) had minor problems (constipation, delayed toilet training or other) and 10 (12.7%) had major problems (need for clean intermittent catheterization, febrile urinary tract infection or reflux). Of 66 patients 30 (45.5%) had abnormal preoperative urodynamics. One of 31 patients (3.2%) had hydronephrosis on preoperative ultrasound. Statistical analysis revealed that abnormal preoperative urodynamics and ultrasound were not predictive of major urological problems. Lipomatous dysraphism and preoperative musculoskeletal symptoms positively correlated with major urological problems (p = 0.0076 and 0.0484, respectively).

CONCLUSIONS

The majority of children did not experience urological problems following tethered cord release. Only a small set of children had major urological problems. Children with lipomatous dysraphism and musculoskeletal symptoms were more likely to experience poor urological outcomes.

Diastematomyelia in children: treatment outcome and natural history of associated syringomyelia

OBJECTIVE

To quantify the long-term outcome of children with diastematomyelia and the implication of syringomyelia in the natural history.

MATERIALS

Retrospective study of 17 children (nine girls and eight boys) with diastematomyelia operated during 1989-2004. Mean age at diagnosis was 3.4 years (range 5 days-12 years), mean follow-up was 5 years; 14 had excision of spur and cord untethering, 3 had excision of spur alone.

RESULTS

The bony spur was in the lumbar region in 12 and thoracic in 5 patients. Syringomyelia was present in eight (47%), associated with bony spur between L1 and 4 (p=0.088), spina bifida occulta in ten (58.8%), and spinal lipoma in one (6%). Preoperative Necker Enfants Malades (NEM) scores were 17 in eight patients, 16 in four, 15 in three, 13 in one, and 12 in one patient. Presenting neurological deficits were motor in eight, sensory deficits in three, and anal incontinence in one patient. There was improvement of NEM scores postoperatively in five patients only, but still with residual deficit. Repeat spur excision and cord untethering was performed in three patients for neurological deterioration 1-4 years after first operation. On postoperative MRI scans syringomyelia remained unchanged in all eight patients. There were one skin infection, one transient motor deterioration, and one patient with sensory deficit after surgery.

CONCLUSION

Prophylactic operations were associated with the best clinical outcome. Despite improvement, all patients with established preoperative deficit still had residual neurological deficits at their last follow-up. The associated syringomyelia remained unchanged after surgery, indicating that it does not contribute to the neurological syndrome.

Terminal syringomyelia communicating with a spinal dermal sinus

Terminal syringomyelia occurs in approximately 25% of patients with occult spinal dysraphism. Congenital spinal dermal sinus is an uncommon form of occult spinal dysraphism. This case report highlights the rare association of terminal syringomyelia communicating with a spinal dermal sinus, resulting in an unique clinical presentation. The clinical, radiological and surgical findings of this unusual case are reported.

Possible genetic correlation of an occipital dermal sinus in a mother and son. Case report

Occipital dermal sinuses (ODSs) are congenital lesions located in the midline and characterized by a cutaneous pit or dimple. The intracranial extension as well as the associated symptoms are variable. To date, a familial occurrence of these lesions has not been reported. In this paper the authors report on a 2-year-old boy with an ODS and intracranial hypertension. The boy's mother had a similar lesion but did not have any complaints. Following their experience with this case and a literature review, the authors suggest that there may be a genetic basis in certain instances of ODS.

Congenital malformations of the skull and meninges

The surgery and management of children who have congenital malformations of the skull and meninges require multidisciplinary care and long-term follow-up by multiple specialists in birth defects. The high definition of three-dimensional CT and MRI allows precise surgery planning of reconstruction and management of associated malformations. The reconstruction of meningoencephaloceles and craniosynostosis are challenging procedures that transform the child's appearance. The embryology, clinical presentation, and surgical management of these malformations are reviewed.

Tethered cord due to spina bifida occulta presenting in adulthood: a tricenter review of 61 patients

Object

Children with spina bifida occulta require early surgery to prevent neurological deficits. The treatment of patients with a congenitally tethered cord who present in adulthood remains controversial.

Methods

The authors studied the medical records of 61 adult patients who underwent surgical untethering for spina bifida occulta at three institutions between 1994 and 2003. Patients who had undergone prior myelomeningocele repair or tethered cord release surgery were excluded.

The most common intraoperative findings were lipomyelomeningocele (41%) and a tight terminal filum (36%). The follow-up duration ranged from 10.8 to 149.5 months. Of the 34 patients with back pain, status improved in 65%, worsened in 3%, remained unchanged in 18%, and improved and later recurred in 15%. Lower-extremity pain improved in 16 patients (53%), remained unchanged in 23%, improved and then recurred in 17%, and worsened in 7%. Lower-extremity weakness improved in 47%, remained unchanged in 47%, and improved and then recurred in 5%. Finally, of the 17 patients with lower-extremity sensory changes, status improved in 35%, remained unchanged in 35%, and the information on five patients was unavailable. Surgical complications included three wound infections, one cerebrospinal fluid leak, and two pseudomeningoceles requiring surgical revision. One patient developed acute respiratory distress syndrome and sepsis postoperatively and died several days later.

Conclusions

Adult-age presentation of a congenital tethered cord is unusual. Despite a slight increase in postoperative neurological injury in adults, surgery has relatively low risk and offers good potential for neurological improvement or stabilization. As they do in children, the authors recommend early surgery in adults with this disorder. The decision to undertake surgery, however, should be modulated by other factors such as a patient's general medical condition and risk posed by anesthesia.

Dr. Ahmet Münir Sarpyener: pioneer in definition of congenital spinal stenosis

Although there are many reports regarding the spinal surgical applications before the 19th century, the definition of spinal disorders and application of the most novel surgical techniques have been performed in last 2 centuries. Lumbar spinal stenosis was reported in the first half of the 20th century. The definition of the lumbar spinal stenosis was commonly attributed to Dr. Verbiest. However, there were some reports regarding the symptoms attributable to lumbar spinal stenosis before him. On the other hand, Dr. Sarpyener, a Turkish surgeon, reported for the first time congenital spinal stenosis, a special variety of spinal stenosis. The aim of this study is to review the biography, scientific studies, and spine applications of Dr. Sarpyener, a pioneer in the field of spina bifida and congenital spinal stenosis.

Paravertebral turnover flaps for closure of large spinal defects following tethered cord repair

Reconstruction of large congenital spinal defects remains a challenge. We present our experience in closure of difficult spinal defects following repair of tethered cord, using paravertebral fascial or myofascial turnover flaps. Between 1996 and 2005, 23 patients were operated using paravertebral turnover flaps for closure of large spinal defects associated with tethered cord. Fifteen (65%) patients had lipomyelomeningoceles. Eleven (48%) patients had sacral defects, 10 (43%) had lumbosacral defects, and 2 (9%) had lumbar defects. Fourteen (61%) patients underwent closure using fascial turnover flaps. Myofascial turnover flaps were used in 9 (39%) patients. Following surgery, none of the patients developed cerebrospinal fluid (CSF) leaks, pseudomeningoceles, or subcutaneous infection. One patient suffered superficial necrosis and infection of the skin suture line, which healed secondarily. We conclude that fascial or myofascial paravertebral turnover flaps provide reliable coverage of difficult defects of the spinal CNS.

Infantile lumbosacral spinal subdural abscess with sacral dermal sinus tract

STUDY DESIGN

Clinical case report of a spinal subdural abscess in an infant presenting with sacral dermal sinus tract (DST).

OBJECTIVES

To suggest that sacral DST with caudal direction may require surgical resection as early as possible.

SUMMARY OF BACKGROUND DATA

DST may induce the formation of a spinal abscess. However, it is sometimes difficult to decide on early surgical resection for DST, especially in cases that are located at a lower level than the lumbar spine and directed caudally that is not accompanied by cerebrospinal fluid leakage.

METHODS

A 9-month-old girl was transferred due to intermittent fever and vomiting, with the midline sinus of the lower back at the second sacral spinal level. She showed mild tenderness of the lower back and slight weakness of both lower extremities with increased residual urine volume of the bladder. Magnetic resonance imaging (MRI) showed that the low-lying sacral DST traced into the subdural space with caudal orientation, and the presence of extensive subdural spinal abscess from the first lumbar spine to the fourth sacrum.

RESULTS

Emergency resection of the sacral DST was performed after laminotomy from the first lumbar spine to the second sacrum, and the subdural spinal abscess was also surgically removed. After 8 weeks of intravenous antibiotic treatment, she showed no neurologic deficit and no evidence of residual abscess on MRI.

CONCLUSION

We suggest that even low-lying sacral DST may require surgical resection as early as possible because it may result in indolent and extensive spinal abscesses.

Spinal capillary hemangioma in infants: report of two cases and review of the literature

We report the case of 2 infants born with a lumbar dermal sinus tract and an overlying angiomatous skin lesion referred to our pediatric neurosurgery service for evaluation of a tethered cord. Both infants were born with a lumbar dimple and were found to have a large cutaneous hemangioma without neurologic symptoms. An MRI of the lumbar spine revealed an isointense mass in the dorsal epidural at L(4) with an adjacent mass effect and extension into the overlying soft tissues. The spinal cord also appeared to be tethered with a fatty filum terminale. We performed a lumbar laminectomy and laminoplasty to remove the mass and to release the tethered cord. Pathologic examination confirmed the diagnosis of capillary hemangioma. Several case reports describe spinal capillary hemangiomas in adults, but only one found in the literature describes a case in an infant. We provide a review of the literature of spinal capillary hemangiomas and support the practice of evaluating infants with cutaneous lumbosacral hemangiomas for underlying spinal cord abnormalities.

Anatomy and surgery of the infected dermal sinus of the lower spine

OBJECT

Cases of infected dermal sinus are scarce and detailed surgical anatomical descriptions are hardly found in literature. The clinical, radiological, and surgical findings in four cases of an infected dermal sinus located at the lower spine are presented to elucidate the pathological anatomical configuration.

CLINICAL MATERIAL

The first case showed two dermal sinuses with a parallel course extra- and intradurally, ending in a confluence of cavities connected to the conus. In this case, as well as in the fourth case, the signs and symptoms were those of meningitis. The second case presented with meningitis and a subdural empyema, while the third case presented with an intradermoid-intramedullary abscess at the junction between the DS and the conus. This child probably showed signs and symptoms of conus involvement as early as during pregnancy.

CONCLUSION

The anatomy of the nervous elements in this congenital anomaly is heavily disturbed, more particularly in case of infection, due to extensive arachnoidal scarring. The latter renders dissection laborious and recognition of anatomical details difficult, resulting in complete excision of a dermal sinus in less than half of the cases. Despite their variability in presentation, most cases of an infected dermal sinus show similar characteristic features.

Congenital spinal dermal sinuses: poor awareness leads to delayed treatment

OBJECTIVE

Congenital spinal dermal sinuses are relatively uncommon congenital abnormalities that result from abnormal neurulation. Lack of awareness about this problem, especially at the primary care level, results in these patients not being managed appropriately. This issue is highlighted in this case series of nine patients.

MATERIALS AND METHODS

The nine patients--six males and three females--were treated over a 3-year period in two centres in the UK and India. The age varied from 212 months to 19 years. Clinical presentations included meningitis or neurological deficits. One was asymptomatic. MRI was done in all cases and showed the sinus tracts in all cases. In five cases, there were intramedullary dermoids and in the others the sinus tract ended either on the dura or blindly. All cases were treated surgically by excision of the sinus and tumour if any. In terms of the neurological status, one became normal, four improved and four remained the same. Of the four who remained the same, two had had normal neurological examination preoperatively. The mean duration from first assessment by a medical practitioner to correct diagnosis and referral to a neurosurgeon was 5 years (range 2 months to 18 years). Proper diagnosis and appropriate management was delayed in these cases because professionals were not aware of this condition.

CONCLUSIONS

Primary care physicians should be made more aware about congenital spinal dermal sinuses. This will facilitate early diagnosis and referral to specialist services.

Treatment of the Occult Tethered Spinal Cord for Neuropathic Bladder: Results of Sectioning the Filum Terminale

PURPOSE

Occult tethered cord syndrome applies to patients with signs and symptoms consistent with a caudal spinal cord malformation despite normal neuroimaging. Although several reports of successful surgical treatment exist, controversy remains with respect to patient selection and efficacy. We present a large series with excellent clinical followup, neuroimaging and urodynamic characterization.

MATERIALS AND METHODS

We present our experience with 36 patients at a single institution with preoperative clinical findings, neuroimaging and urodynamics available. Postoperative outcomes were assessed clinically and with urodynamics. We determined predictive parameters to improve patient selection.

RESULTS

Approximately 0.04% of pediatric urology clinic visits resulted in neurosurgical referral for the potential of an occult tethered cord. They occurred after failure of a mean of 2 years of aggressive medical management. Daytime urinary incontinence was present in 83% of patients and 47% had encopresis. Preoperative urodynamics were markedly abnormal in all patients with mean bladder capacity 55% of expected capacity. Clinical improvement in urinary symptoms was seen in 72% of patients with resolution of incontinence in 42%. Bowel symptoms improved in 88% of cases, including resolution of encopresis in 53% within 3 months of surgery. Urodynamic improvements were demonstrated in 57% of cases. We were unable to determine preoperative factors that were more likely associated with surgical success.

CONCLUSIONS

In a highly select population with severe urinary and fecal dysfunction sectioning a normal-appearing filum terminale can result in significant improvement. We were unable to identify factors that may increase the chance of surgical success.

Outcome in Patients Who Underwent Tethered Cord Release for Occult Spinal Dysraphism

PURPOSE

Tethered cord syndrome encompasses a group of clinical symptoms caused by abnormal spinal cord fixation. We evaluated a select cohort of patients with primary tethered cord syndrome in regard to urodynamic and clinical outcome after cord release.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients with the diagnosis of tethered cord from May 2001 to October 2004. Patients were assessed preoperatively by standard urodynamic studies, which was repeated a mean of 6.4 months after tethered cord release. Clinical and urodynamic outcomes were analyzed.

RESULTS

Ten male and 14 female patients 1 month to 12 years old (median age 6 years) were evaluable. Preoperatively 14 of the 24 patients with a median age of 8.1 years were toilet trained and 7 (50%) had diurnal incontinence. Constipation was noted in 10 of 24 patients (42%) and urinary tract infections developed in 6 (25%). Postoperatively only 1 patient (7%) experienced diurnal incontinence (p = 0.04). Constipation was observed in 6 patients (25%) and urinary tract infections developed in 1 (4.2%) (p = 0.29 and 0.07, respectively). Ten of the 21 children (48%) with abnormal urodynamics had normalized studies postoperatively. Ten of the 17 patients with neurogenic detrusor overactivity achieved normalization and 7 remained unchanged. Two of 3 patients with normal preoperative urodynamics had neurogenic detrusor overactivity and 1 had poor bladder compliance. Four patients with low bladder capacity and/or low compliance preoperatively did not improve.

CONCLUSIONS

Our results suggest that tethered cord release is beneficial in terms of clinical and urodynamic outcomes. Patients with abnormal urodynamics had 48% improvement after tethered cord release. Neurogenic detrusor overactivity seems to respond better with 59% improvement in urodynamics. The level of the conus on magnetic resonance imaging did not seem to be predictive of urodynamic outcome. Patients with a normal bladder may show urodynamic deterioration postoperatively, which raises cause for concern.

Occult tethered cord syndrome: not an indication for surgery

OBJECT

The author describes the paucity of information known about occult tethered cord syndrome and summarizes the argument for using a nonsurgical approach in these cases.

METHODS

A review of what we do and do not know about this syndrome is provided. Surgical procedures to divide the terminal filum in patients with symptoms of tethered spinal cord without the imaging correlates are said to result in clinical improvement, yet there is little physiological evidence to support the surgical release of the filum in the absence of other anatomical lesions. Validated diagnostic and outcome measures are also lacking, which makes the interpretation of reported results exceedingly difficult. Finally, reports used to support surgical intervention are limited by small size, the absence of control groups, and observer bias.

CONCLUSIONS

Without conclusive clinical evidence, the arguments supporting surgery for occult tethered cord syndrome must be viewed cautiously.

Occult tethered cord syndrome: a survey of practice patterns

OBJECT

Tethered cord syndrome (TCS) is associated with a number of congenital anomalies involving early development of the spinal cord. These include myelomeningocele, spinal cord lipoma, low-lying conus medullaris, and a fibrofatty terminal filum. Occult TCS occurs in patients when clinical features indicate a TCS but the typical anatomical abnormalities are lacking. It is controversial whether surgical release of the terminal filum leads to clinical improvement in a patient who does not have a previously identified anatomical abnormality. To assess the clinical standard used by practicing pediatric neurosurgeons, a practice survey was conducted at the 2004 Annual Meeting of the Joint Section for Pediatric Neurological Surgery of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

METHODS

The survey examined clinical decision making for a same-case scenario with differing appearance on imaging studies. There was a clear consensus regarding diagnosis and treatment in the patient with symptoms, a low-lying conus medullaris, and a fatty terminal filum. The vast majority of respondents (85%) favored surgical untethering for this patient. A majority of respondents (67%) also favored treatment for the patient having symptoms and a fatty terminal filum. There was, however, significant disagreement regarding the diagnosis and treatment of disease in one patient with symptoms and an inconclusive magnetic resonance imaging study. Some respondents clearly favored surgery, whereas others believed that this patient did not meet the diagnostic criteria for TCS.

CONCLUSIONS

The results of this survey support the development of a randomized clinical trial to address the benefit of surgery for occult TCS.

Basicranial diplomyelia: an extension of the split cord malformation theory. Case report

Basicranial diastematomyelia is an extremely rare congenital disorder. A review of the literature indicates only one reported case of basicranial diastematomyelia in which an osseous peg divided the brainstem in two. The authors present the first reported case of basicranial diplomyelia split by a fibrous band and correlate its pathogenesis with that of split cord malformation (SCM). The patient described in the present report had a fibrous stalk dividing the brainstem, and therefore the condition was categorized as a diplomyelia, or SCM Type II. Because the occipital dermatomes behave similarly to the spinal dermatomes early in development, they may be subject to the same embryonic error that results in SCM. The authors propose that the mechanism leading to SCM is the same as that found in basicranial split malformations and that the theory explaining it be modified to include the posterior fossa.

Occult tethered cord syndrome: the case for surgery

OBJECT

Controversy exists regarding proper indications for surgical lysis of the terminal filum in children with voiding dysfunction and tethered spinal cord. Recently, surgery has been offered to children who have a normally positioned conus medullaris and no terminal filum abnormality visible on 1.5-tesla magnetic resonance images (referred to as minimal or occult tethered cord syndrome [TCS]). The author evaluates existing clinical and scientific evidence relevant to this controversy.

METHODS

Five retrospective, observational, noncontrolled studies of surgical terminal filum lysis for occult TCS in children were identified. Two further studies in which the authors reported surgical results in children with a normal-level conus medullaris were also identified.

CONCLUSIONS

These studies document encouraging clinical outcomes following surgery. Clinicopathological evidence suggests that occult TCS may result from radiographically occult structural abnormalities of the terminal filum. Although a preponderance of Class III clinical evidence supports the use of surgical filum lysis to treat occult TCS, no Class I or II evidence exists. Clinical practice varies; therefore, performance of a prospective randomized clinical trial of surgical terminal filum lysis for the treatment of occult TCS is advocated.

A simple method to deter retethering in patients with spinal dysraphism

OPERATIVE TECHNIQUE

The authors describe a technique that may be of benefit to patients with spinal dysraphism and a tethered spinal cord. Twenty pediatric patients (ten initial operations and ten reoperations) after the detethering of their spinal cord had intradural retention sutures placed with subsequent duraplasty using autologous thoracolumbar fascia.

RESULTS

To date, no patient has had signs or symptoms or recurrence of signs or symptoms of a tethered spinal cord. No complications have resulted from this maneuver. The mean follow-up time for this cohort was 8 years. The advantages of this intervention include maintaining a relatively normal position of the spinal cord within the thecal sac, thus decreasing the potential adherence of the dorsally scarred aspect of the dysmorphic cord to an overlying graft whether synthetic or native.

Holocord intramedullary abscess due to dermal sinus in a 2-month-old child successfully treated with limited myelotomy and aspiration. Case report

This 2-month-old child presented with paraplegia. The authors observed a dermal sinus with purulent discharge in the lumbosacral area. Magnetic resonance (MR) imaging of the spine revealed an intramedullary enhancing cavity spanning C-1 to the conus medullaris. Intraoperatively the dermal sinus was seen to infiltrate the lower end of the conus medullaris, and it also communicated directly with the central canal. The L2-5 laminae were removed, and a myelotomy was undertaken on the conus medullaris. A No. 8 French pediatric feeding tube was passed into the abscess cavity and advanced rostrally to the level of C-1. Aspiration was applied via the feeding tube to drain the intramedullary abscess of the spinal cord (IASC). Postoperatively, a 6-week course of intravenous cloxacillin was instituted. Follow-up MR imaging revealed complete resolution of abscess. When the patient was 26 months of age, examination showed complete neurological recovery. The authors describe what, to their knowledge, is the first case of a holocord IASC treated successfully by the aforementioned technique, and review of the related literature.

Intradural cranial congenital dermal sinuses: diagnosis and management

OBJECTIVE

The congenital dermal sinus (CDS) is a benign tumor-like entity that has unique anatomical and clinical features. We retrospectively examined our data to determine factors associated with adverse outcomes for cranial-based dermal sinuses.

METHODS

We retrospectively examined our data obtained from patients presenting between 1975 and 2002. Sixty-seven patients with a CDS were found. Of these, 20 cases of a cranial CDS were identified, 15 of which had evidence of an intradural component.

RESULTS

Surgical treatment of congenital dermal sinuses was accompanied with, in general, excellent results. Poor outcomes were most strongly associated with delays in diagnosis. The most common complications were infection at the surgical site (five patients) and hydrocephalus necessitating ventriculoperitoneal shunt placement (two patients). Permanent neurological deficits were rare.

CONCLUSION

Cranial CDSs are unusual lesions found in children. A majority of these lesions may penetrate the dura and lead to significant complications if not promptly identified and treated in an appropriate and timely fashion.

Prenatal diagnosis of occipital dermal sinus associated with hemangioma using ultrasound and MRI. Case report

OBJECTIVE

We report a case of prenatal diagnosis and postpartum management of a subcutaneous tumor without intracranial communication.

METHODS

An occipital tumor without intracranial communication was found on ultrasound scan in the 21st week of pregnancy. Using MRI, the diagnosis was confirmed. Subcutaneous localization of the tumor was verified and communication with intracranial space excluded.

RESULTS

The newborn was delivered spontaneously at term and underwent a successful surgical procedure 5 months postpartum.

CONCLUSION

The prenatal diagnosis allowed differentiation between a communicating neural tube defect with poor prognosis, and a manageable extracranial subcutaneous tumor. The precise diagnosis of uncomplicated dermal sinus was possible only after the histological evaluation of the tumor confirmed occipital dermal sinus associated with hemangioma.

Cerebellar dermoid cyst with occipital dermal sinus. Report of two pediatric cases

Intracranial dermoid cyst is a rare entity accounting for 0.1-0.7% of all intracranial tumors. The most common location is in the posterior fossa, at or near the midline. We present 2 pediatric cases with dermal sinus. The first case presented with clinical signs of increased intracranial pressure and cerebellar symptoms. CT scan showed a large and regular midline posterior fossa cyst without contrast enhancement. The second case was revealed by recurrent meningitis. CT scan showed a midline vermis low-density mass with capsular contrast enhancement. Dermal sinus was found in 2 cases. Complete surgical removal was performed followed, in a second operation, by ventriculoperitoneal shunt in 2 cases. There was no postoperative complication in our patients. The aim of this study is to discuss the clinical aspects of dermoid cyst, especially in cases with dermal sinus, and to review the therapeutic strategies in case of associated hydrocephalus.

A lateral cervical lipomyelomeningocele associated with diplomyelia

We report a case of a neonate with complex spinal dysraphism and associated anomalies of the axial skeleton. Based on the clinical presentation and radiographic findings, and recent advances in the understanding of human embryogenesis, we formulate a hypothesis that such a presentation is the result of failure of normal gastrulation. A 1-day-old male neonate presented with multiple right-sided anomalies, including hypoplastic right face and decreased movement of the right upper extremity. Radiographic studies demonstrated absent right cervical hemivertebrae, right cervical lipomyelomeningocele, and cervical diplomyelia with right hemicord terminating in a blind pouch. Anterior and posterior cervical and thoracic fusion with instrumentation was performed at the age of 3 years, and on follow-up the patient had improvement in right upper extremity strength. Complex spinal dysraphism is a pathological process that occurs during different stages in human development. We describe a case involving a rare lateral lipomyelomeningocele in the cervical-thoracic area.

The intermediate type split cord malformation: hypothesis and case report

METHODS

A patient is described in which a complete osteofibrotic dorsally implanted septum was found in combination with a split cord malformation in a single dural tube. This case cannot be explained using the widely used theory as proposed by Pang et al. [Pang D, Dias MS, Ahab-Barmada M (1992) Split cord malformation, part I: A unified theory of embryogenesis for double spinal cord malformations. Neurosurgery 31:451-480] but must be regarded as a combination of type I and II split cord malformation.

RESULTS

The authors state that all types of split cord malformation can be reduced to a single derailment during development, with various degrees of severity.

CONCLUSIONS

The configuration of the malformation is determined by the way the median parts of the mesoderm come to development. Type I and II split cord malformation are not distinct entities.

[Unilateral spondylolysis with spina bifida occulta of lumbar spine--case report and review of the literature]

Unilateral spondylolysis and midline defects in the posterior spinal elements attributable to spina bifida occulta (SBO) result in the unilateral floating of the vertebral arch. We report a patient with unilateral spondylolysis associated with SBO in the lumbar spine and review the literature. This 71-year-old male experienced severe left leg pain and lumbago that worsened upon walking. Radiographic studies revealed SBO and unilateral spondylolysis of L5. The dural sac and left L5 nerve root were compressed by the organization of tissues around the spondylolysis. As his symptoms failed to respond to conservative treatment, he underwent unilateral laminectomy without fusion. At operation, the left lamina of L5 was floating and unstable; the right lamina was stable. Medial facetectomy at L4/5 and excision of the left floating lamina of L5 were performed. For satisfactory decompression of the dural sac and left L5 nerve root, the cartilaginous fibrous tissue around the lysis was removed. His symptoms disappeared immediately after surgery. Although long-term follow-up is necessary, we suggest that unilateral microdecompression without fusion is a useful method to treat patients with unilateral spondylolysis with SBO.