Coagulopathy associated with large sacrococcygeal teratomas

Twelve neonates with sacrococcygeal teratoma (SCT) have been treated at British Columbia Children's Hospital over the past 5 years. Clinically significant coagulopathy developed in four of these neonates and two died, one before surgical intervention could be undertaken. Disseminated intravascular coagulation (DIC) was found in one patient and thrombocytopenia in another on preoperative laboratory studies. Etiology of the coagulopathy is unclear, but appears to be multifactorial. Although several clinical reviews have noted mortalities due to exsanguinating hemorrhage, no study has focused solely on this issue. The diagnosis of SCT in the neonate at high risk for development of coagulopathy is usually made prenatally. Premature labor is often precipitated by associated polyhydramnios and large tumor size. Fetal distress, prematurity, and low birth weight are common. Presence of placentamegaly, hydrops fetalis, and congestive heart failure are ominous prognostic signs. Early identification of patients at increased risk for development of hemorrhagic complications may allow optimization of their management. Cesarean section should minimize trauma to the SCT during delivery. Expeditious resection of the lesion may improve survival.

Vertebral abnormalities associated with congenital sacrococcygeal teratomas

An orthopedic and radiologic follow-up study was performed on 45 patients who had undergone surgery for a benign congenital sacrococcygeal teratoma (SCT). Eighty percent of the patients had one to three vertebral abnormalities at the mean age of 21 years. Extrapelvic primary tumors were associated with subsequent development of spondylolysis in the lumbosacral spine, and intrapelvic primary tumors were associated with multiple spina bifida occulta lesions and other spinal anomalies. In addition, an increased incidence of congenital dislocation of the hip (7%) was observed in patients with SCTs.

[Prenatal diagnosis of a sacrococcygeal teratoma with hydrops fetalis and placental hypertrophy--consequences for the further course of pregnancy]

A fetal sacrococcygeal teratoma may cause hypertrophy of the placenta and fetal hydrops. This is dangerous for the fetus and also for the mother. The maternal risk results from preeclampsia and respiratory insufficiency, associated with elevated beta-HCG. In that case, pregnancy should be terminated by caesarean section due to maternal reasons.

Long-term results of surgical treatment of spinal lipomas. Report of 18 cases

We report the long-term results of surgery on spinal lipomas in a series of 18 patients. Four patients had congenital lipomas with spina bifida and/or myelomeningocele and the other fourteen had tumoural (true) lipomas. Simple decompression or subtotal removal afforded a very good prognosis in all patients with intradural lipomas whose preoperative neurological deficits were slight. In the light of the long follow-up, the lack of difference in biological behaviour between congenital and tumoural (true) lipomas leads us to regard the two types as a single maldevelopment entity of dysembryogenetic origin.

[Life-threatening perinatal hemorrhage of a sacral teratoma]

Great sacral teratomas are rare congenital tumors. The frequency in liveborns is about 1:40,000. Well known complications of sacral teratomas are malignant degeneration, infection and, in case of intraabdominal expansion, compression of the urogenital tract. We report a case of unusual fulminant perinatal bleeding out of a great sacral teratoma ruptured during birth.

[The clinical problem of the tethered cord syndrome--a report of 3 personal cases]

Tethered cord syndrome is defined as a low state of the conus medullaris below the lumbar vertebra 2 after the neonatal period. Possible causes are: short thickened filum terminale, fibrotic ligaments, intradural lipomas. The clinical course is characterised by motoric and sensory deficits, disturbances of balance, neurogenic bladder disturbances, foot deformities and backache. A 3-year-old boy after operation of a lipomyelomeningocele at 2 months showed a one-sided leg shortening and a progressive neurogenic bladder and intestinal disturbance. The cause was a low state of the conus with a shortened filum terminale and a remainder of a lipoma. A 7-year-old boy after operation of a thoraco-lumbar meningomyelocele developed a progressive asymmetric paraspastic state with contractures. The neuro-radiological diagnosis of an intradural dermoid was verified on operation. A 10-year-old boy after operation of a covered lumbosacral meningocele showed a progressive backache which was connected with flexion. We found a low state of the conus through adhesions caused by scars which could be removed operatively. A collaborative treatment by the paediatric surgeon and the neuro-paediatrician of patients with dysraphic disturbances can prevent the severe consequences of the tethered cord problems with the co-operation and early intervention of the neuropaediatric surgeon.

Magnetic resonance imaging of lipomyelomeningocele and tethered cord

The operative and magnetic resonance image (MRI) findings of 25 patients with the diagnosis of lipomyelomeningocele and/or tethered cord were compared. Postoperative MRI scans of eight patients, five of whom were in stable condition, were also compared with the preoperative studies. In this review there was one false negative MRI scan and four MRI scans in which the relationship of the lipoma to the conus or filum was not demonstrated accurately. In six patients, incidental intramedullary cystic lesions at the conus were identified by MRI scan. All eight postoperative (1 month to 2 years) scans demonstrated no change in the level of the conus from the preoperative study. MRI is an accurate screening modality in the initial diagnosis of occult spinal dysraphism. MRI was not useful in the postoperative evaluation of lipomyelomeningocele and the tethered cord, since the caudal, posterior displacement of the conus was unchanged in all studies.

Correlation between magnetic resonance imaging and surgical findings in the tethered spinal cord

Between October 1982 and August 1987, 20 patients underwent magnetic resonance imaging (MRI) and subsequent surgical release of a tethered spinal cord. The tethering was caused by a thick filum terminale in 6 patients. On MRI scans, the conus medullaris was at L4 in 2 patients, at L2 in 3 patients, and the filum terminale appeared thick in 1 patient. The spinal cord was tethered to an intradural lipoma correctly demonstrated by MRI in 6 patients. Increased epidural fat was misdiagnosed as an intradural lipoma in one patient and a lipomatous stalk was not identified in 2 other patients. Scar tissue resulting from repair of a meningocele had tethered the cord in the remaining 8 patients. On MRI scans, the conus medullaris was located between L3 and S3; in 5 of the patients, scar tissue was apparent on the MRI scan. This correlative study supports the use of MRI as the initial, and possibly the only, imaging modality when a tethered spinal cord is suspected. Improved or more recent MRI techniques will help demonstrate these anomalies better.

Nuclear magnetic resonance computerised tomography (NMR-CT) in early diagnosis of dumbbell neuroblastoma

This is a report on a dumbbell neuroblastoma with intraspinal extension first noted by 99mTc-HMDP imaging and CT, and confirmed by NMR-CT before the symptoms of spinal cord compression become clear. Paravertebral neuroblastoma and its intraspinal involvement were successfully excised following laminectomy and abdominal surgery without any residual neurologic complications. We report this case to emphasise that NMR-CT was particularly useful to diagnose the extent of intraspinal portion of the tumour, and should be performed in any patient who presents with neuroblastoma adjacent to the vertebral body.

[Sacral teratomas in childhood. An analysis of long-term results in 87 children]

52 patients were followed up out of a total of 87 children with sacrococcygeal teratomas, within a period of 25 years, from three paediatric surgery hospitals and out of altogether 73 survivors. The results in 35 children where the operation had been performed more than three years ago, were classified as "late results". From this group, 18 children were followed up by clinical examination only, without detecting any dysfunctions. By the additional use of electromanometry of urinary bladder and rectum, however, bladder and rectum dysfunctions were seen in about 40% of 17 further children. These dysfunctions were partly myogenic and partly neurogenic in nature and were directly related to the size, tumour status and intrapelvic extension of the sacrococcygeal teratoma.

Congenital intraspinal lipomas: clinical presentation and response to treatment

A retrospective review of 29 patients with surgically treated intraspinal lipomas was conducted in a determination of their manner of presentation and response to treatment. The average age at the time of diagnosis for the entire group was 12.8 years. Only five patients were neurologically normal by clinical examination at the time of diagnosis, and these five patients were all less than 6 months old. Orthopedic intervention was judged successful in each of the 11 foot-procedures done after surgery on the lipoma, but in only two of the five foot procedures done before such surgery. We conclude that consideration of intraspinal lipoma is worthwhile in several circumstances, including pediatric foot deformities.

Congenital ependymoblastoma presenting as a sacrococcygeal mass in a newborn: an immunohistochemical, light and electron microscopic study

We describe a case of congenital ependymoblastoma presenting as a subcutaneous mass in the sacrococcygeal area of a newborn male. The tumor was composed of primitive cells disposed in compact sheets and cords and exhibiting focal ependymal differentiation. No other line of cellular differentiation was identified by either immunohistochemistry or ultrastructural study. Elevated serum alpha-fetoprotein was found, which decreased following surgical extirpation of the tumor. We propose that this tumor had its origin in the ependymal medullary vestige, similar to other sacrococcygeal ependymomas.

[Delivery planning and interdisciplinary management of large coccygeal teratomas]

Prenatal sonographic screening and a growing experience of examiners with regard to possible congenital malformations such as large coccygeal teratomas have induced the request for an early interdisciplinary consultation between obstetrician, human geneticist, paediatric surgeon, neonatologist and psychologist. It should aim at a careful information and counselling of the parents with regard to the mode of delivery and possibilities of operative management. The prerequisites for far sighted planning and performance of delivery are demonstrated by the example of large coccygeal teratomas. The availability of equipment, facilities and manpower at the time of delivery guarantees a course of delivery at reduced risk and is, together with the psychological guidance of the parents, a basic element of optimal care for the newborn.

The presentation and management of presacral tumours

Twenty cases of presacral tumours are presented, nine males and eleven females being affected. Malignancy occurred in 50 per cent of adults and was commoner in men than in women. Diagnosis depends on a careful rectal examination. Computerized axial tomography is the single most useful investigation; however, should it not be available, plain X-rays and ultrasonography give considerable information. For lesions less than 10 cm in size a local parasacral approach is often feasible but for larger lesions an abdominal approach or combined approach should be considered.

Are the metabolic characteristics of congenital intraspinal lipoma cells identical to, or different from normal adipocytes?

Congenital intraspinal lipomas are frequently responsible for progressive neurological deficits caused by distortion or compression of the nervous system. Since fat metabolism in these lesions has not been previously studied, the aim of this study was to determine whether intraspinal lipoma cells behave like lipomas or like normal adipocytes. In 11 patients, intraspinal lipoma cells were compared with normal adipocytes isolated from adjacent subcutaneous adipose tissue for the following parameters: lipoprotein lipase (LPL), lipogenesis from U14C glucose, beta-receptor number, adenylate cyclase activity, cyclic AMP production, and lipolysis in response to beta- and alpha 2-adrenergic agonists. No significant difference between these two cell populations was found, suggesting that intraspinal lipomas are not lipomatous tumors, but hamartomatous lesions capable of growth and regression along with the changes in the rest of the fatty pool. This emphasizes the danger of an abnormal weight gain, as well as the possible usefulness of an hypocaloric diet in patients who worsen in spite of previous surgery.

Surgically confirmed myelographic classification of congenital intraspinal lipoma in the lumbosacral region

Twenty-four cases of histologically confirmed congenital intraspinal lipoma of the lumbosacral region were studied by means of myelography with metrizamide. The findings were compared with intraoperative observations. Myelography with metrizamide clearly revealed the detailed intrathecal structures and allowed a classification of intraspinal lipomas into four types, in terms of their insertion into the conus medullaris: dorsal type, either with direct or indirect (via an intrathecal stalk) insertion of the extrathecal lipoma into the dorsal aspect of the conus medullaris; caudal type; combined type; and filar lipoma. Based on our surgical experience in untethering and decompression of the lesions, the classification was found to be useful in designing a safe and effective surgical procedure which minimized all possible trauma to the intrathecal neural structures.

Congenital intraspinal neuroblastoma with intraspinal calcification in the neonatal period: report of a case with a 32-year follow-up

Punctate and amorphous intraspinal calcification associated with interpediculate widening in a neonate with lower extremity paresis is probably pathognomonic for congenital calcified intraspinal neuroblastoma.

Surgical treatment of spinal lipomas in infancy and childhood

The clinical course and surgical treatment of 48 children with lipomatous lesions of spinal dysraphism are presented. Preoperative studies consisted of complete neurological examination, IVP, myelography and CT scan if indicated. The complete clinical course and surgical treatment of the children with lipomatous lesions of the lower spine is reviewed. The surgical aim was to free all intra- and extradural adhesions by dural grafting if necessary. The results of surgical treatment are dependent upon the time of treatment (as early as possible), the location and extent of the malformation and the quality of surgical treatment.

Derangement of neuronal migration in a child with multiple congenital anomalies, two congenital neoplasms, without apparent chromosomal abnormalities

A live-born male infant with multiple severe abnormalities, two congenital neoplasms, a neuroblastoma and nephroblastoma, and without apparent chromosomal abnormalities, is described. The neuropathologic findings were a holoprosencephalic type defect with disturbance of neuronal migration to the cortical plate. Comparison of the overall findings with cases presenting similar multiple congenital abnormalities indicates that this case either demonstrates previously unrecognized features of these syndromes, or is unique.

Congenital intraspinal neuroblastoma

Congenital neuroblastoma is a well-recognized entity with a very favorable prognosis for tumor cure. However, a newborn with neurologic deficit owing to intraspinal extension of this tumor is very unusual. Eleven such cases in the world literature are reviewed, and an additional case of a new born with paralysis and a neurogenic bladder at birth is presented in detail. The prognosis for tumor cure is excellent regardless of the mode of therapy used. Because of this fact, treatment should include safe surgical decompression and chemotherapy only. The outlook for the return of normal neurologic function is poor.