The simple sacral dimple: diagnostic yield of ultrasound in neonates

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..

Update on Pediatric Spine Imaging

The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors.

Tethered Cord Syndrome: Role of Imaging Findings in Surgical Decision-Making

For infants presenting with urinary problems or lower extremity weakness, imaging is ordered to investigate spinal pathology. Tethered cord syndrome (TCS) often manifests without conclusive anatomic evidence. In our case, a premature infant presented with urosepsis and was found to have an asymmetric gluteal crease and a sacral dimple. Renal ultrasound showed mild hydronephrosis, and a cystourethrogram revealed bilateral high-grade vesicoureteral reflux. Ultrasound and magnetic resonance imaging demonstrated a borderline low-lying spinal cord at the mid-L3 vertebral level. Urodynamic testing to confirm neurogenic bladder could not be completed on the first attempt due to urinary tract infection and on the second attempt due to instrument intolerance. Despite the lack of conclusive imaging evidence of a tethered cord, enough supportive clinical data was present to proceed with surgical intervention with the goal of preventing the progression of neurological dysfunction. Because TCS is ultimately a clinical diagnosis, appropriate management should not be discouraged by inconclusive or borderline imaging findings.

Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change

Substantial relaxation of natural selection beginning around 1900 changed the mutation/selec­tion balance of modern genetic material, producing an increase in variable anatomical structures. While multiple structures have been affected, the temporal increase in variations of the sacrum, specifically, ‘Sa­cral Spina Bifida Occulta,’ have been reliably demonstrated on a localised scale. Calculation of largescale frequency has been hindered by the localised nature of these publications, the morphological variability of this variation, and potential pathological associations, which have produced divergent classifications, and conflicting reported rates of occurrence. A systematic review of the reported literature was conducted to provide an objective analysis of Sacral Spina Bifida Occulta frequency from 2500 BCE to the present. This review was designed to compensate for observed inconsistencies in reporting and to ascertain, for the first time, the temporal trajectory of this secular trend. A systematic review of Sacral Spina Bifida Occulta lit­erature was conducted through the strict use of clinical meta-analysis criteria. Publications were retrieved from four databases: PubMed, Embase, the Adelaide University Library database, and Google Scholar. Data were separated into three historical groups, (1 = <1900, 2 = 1900 to 1980 and 3 = >1980), and frequency outcomes compared, to determine temporal rates of occurrence. A total of 39/409 publications were included in the final analysis, representing data for 16,167 sacra, spanning a period of 4,500 years. Statistically significant results were obtained, with total open S1 frequen­cy increasing from 2.34%, (79 to 1900CE), to 4.80%, (1900 to 1980CE) and to 5.43% (>1980CE). These increases were significant at p<0.0001, with Chi-squared analysis. A clear secular increase in the global frequency of Sacral Spina Bifida Occulta has been demonstrated from 1900 to the present. This research provides a novel and adaptable framework for the future assessment of variation distribution, with impor­tant implications for the fields of biological anthropology and bioarchaeology.

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.

International survey on the management of lumbosacral cutaneous stigmata in infants with suspected occult spinal dysraphism

OBJECTIVE

Occult spinal dysraphism (OSD) is a common pediatric neurosurgical diagnosis rife with controversy surrounding both the screening of asymptomatic infants and the threshold to offer a prophylactic detethering operation. The authors sought to clarify international practice patterns with a survey of pediatric neurosurgeons.

METHODS

A survey asked pediatric neurosurgeons whether they would perform imaging in patients with a variety of cutaneous stigmata associated with OSD and whether they would offer prophylactic detethering surgery for asymptomatic patients with a variety of imaging findings on the OSD spectrum.

RESULTS

Completed surveys were received from 141 pediatric neurosurgeons. Broad consensus was demonstrated on the need for obtaining images in sample patients with more severe stigmata ranging from large lipoma with a skin appendage to focal dysplastic skin in the lumbar midline. Ninety percent of respondents would perform MRI for these patients. In contrast, for patients with a low-sacral dimple, flat hemangioma, and symmetric (Y-shaped) splaying of the intergluteal cleft, opinion on the need for imaging varied considerably (between 57% and 89% recommended imaging). Respondents differed on the type of imaging that they would perform, with 31% to 38% recommending ultrasound screening. The responses reflected less consensus on when to offer surgery to patients with simple spinal tethering (low-lying conus medullaris and fatty filum terminale). Both a lower level of the conus and increased thickness of the filum terminale affected decision-making.

CONCLUSIONS

The results of this survey showed significant consensus on the recommendation for screening imaging in patients with more dramatic cutaneous stigmata, although these stigmata are the rarest. A significant variance in opinions was reflected in the recommendation for imaging of the most common cutaneous stigmata. Consensus was also lacking on which lesions deserve prophylactic detethering surgery. Significant equipoise exists for future study of screening imaging and of surgical decision-making in patients with asymptomatic OSD and associated cutaneous stigmata.

The Term Newborn: Postnatal Screening and Testing

Prenatal genetic screening, including evaluation for inherited genetic disorders, aneuploidy risk assessment, and sonographic assessment, combined with a thorough newborn examination and standard newborn screening, including blood, hearing, and congenital heart disease screening, can reveal conditions requiring further evaluation after delivery. Abnormal prenatal or newborn screening results should prompt additional diagnostic testing guided by maternal fetal medicine, perinatal genetics, or pediatric specialists.

A Hospital Based Cross Sectional Study of Midline Cutaneous Lesions in Neonates and its Association with Spinal Dysraphism Detected Using Ultrasound

Background:

Spinal dysraphism occurs due to incomplete fusion of the midline mesenchymal, bony, or neural elements of the spine. The defects in the spinal cord can be associated with skin lesion since both have same embryonic origin.

Aims and Objectives:

This study was conducted to determine the association of midline and paramedian cutaneous lesions with spinal dysraphism by using spinal ultrasonography.

Materials and Methods:

Two thousand apparently healthy neonates were screened in the postnatal ward of a tertiary care center in South India. Those neonates with cutaneous lesions in the midline and paramedian region were screened for evidence of spinal dysraphism by using spinal ultrasonography.

Results:

Among 2000 neonates, 120 (6%) had at least one cutaneous lesion, of which 114 (5.7%) were in the midline and 6 (0.3%) were on the paramedian region of dorsal and ventral aspect of the body. Among these neonates, two cases had more than one skin lesions. The most common cutaneous lesion observed was typical dimple (82, 68%) followed by hypertrichosis (12, 10%). Ultrasonography revealed spinal anomaly in six (5%) of them. The cutaneous lesions associated with spinal dysraphism were obvious midline swelling, dermal sinus, and multiple skin lesions.

Conclusion:

Congenital midline and paramedian skin lesions may be the marker of spinal dysraphism. In the presence of such cutaneous lesions, only 5% of them had associated spinal anomaly in our study.

Incidence of Occult Spinal Dysraphism Among Infants With Cutaneous Stigmata and Proportion Managed With Neurosurgery: A Systematic Review and Meta-analysis

IMPORTANCE

Occult spinal dysraphism (OSD) is the most common congenital spinal anomaly. Cutaneous anomalies such as skin dimples or deviated gluteal folds are well known as stigmata of OSD and are indicators for further evaluation; however, the association between cutaneous anomalies and OSD has not been systemically evaluated.

OBJECTIVE

To evaluate the incidence of OSD and the proportion of OSD cases managed with a neurosurgical intervention among neonates or infants with various cutaneous stigmata.

DATA SOURCES

PubMed and Embase databases were searched for studies published up to July 25, 2018, that evaluated the proportion of OSD cases in neonates or infants with cutaneous stigmata. Search terms included ultrasound, dysraphism, dimple, and infant or neonate. The search was limited to English-language publications.

STUDY SELECTION

Two reviewers selected the studies evaluating the incidence of OSD among neonates or infants with cutaneous stigmata.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data extraction were followed. Pooled proportions of OSD cases and OSD cases that were managed with a neurosurgical intervention were obtained using the generalized linear mixed model and maximum likelihood method.

MAIN OUTCOME AND MEASURES

The pooled incidence of OSD and OSD cases managed with neurological surgery among patients with cutaneous stigmata was the primary outcome. This outcome was also evaluated in each subgroup, and heterogeneity was explored using subgroup analysis.

RESULTS

A total of 15 studies, involving 6558 neonate or infant patients with various cutaneous stigmata, were included. The pooled proportion of OSD cases among the patients with cutaneous stigmata was 2.8% (95% CI, 2.1%-3.8%; I2 = 51.6%), and the proportion managed with neurological surgery was 0.6% (95% CI, 0.3%-1.3%; I2 = 66.4%). Cases with combined stigmata showed a significantly higher association with OSD than those with a single stigma (10.5% [95% CI, 6.9%-15.8%] vs 2.3% [%, 95% CI, 1.5%-3.5%]; P < .001). The pooled proportion of OSD cases among patients with an atypical dimple was significantly higher than among those with simple dimple (8.8% [95% CI, 4.5%-16.6%] vs 0.6% [95% CI of 1.4%-2.1%]; P = .001).

CONCLUSIONS AND RELEVANCE

The proportion of OSD in healthy, asymptomatic patients with midline cutaneous stigmata was low, and the proportion of patients who underwent a neurosurgical intervention was even lower. However, a careful evaluation as well as potential spinal magnetic resonance imaging is recommended for neonates or infants with combined stigmata or an atypical dimple for possible high-risk lesions.

Filum terminale lipoma revealed by screening spinal ultrasonography in infants with simple sacral dimple

PURPOSE

Spine ultrasound (US) examinations are widely performed in neonates and infants with sacral dimple to exclude associated congenital malformations. Increased utilization of, and improvements in, sonographic technology has resulted in the frequent identification of echogenic filum terminale (FT) containing fat below the conus medullaris, termed FT lipoma or fatty FT. We examined the value of screening US, especially for diagnosis of FT lipoma, in infants with "simple sacral dimple."

METHODS

This study was a retrospective review of spinal US and magnetic resonance imaging (MRI) findings performed in our hospital on full-term and preterm infants with simple sacral dimple. We reviewed the clinical records and spinal sonographic scans of 337 patients, and the MRI scans of 40 patients with simple sacral dimple. We evaluated the thickness and echogenicity of FT on US, and the presence of fat in the FT was determined by MRI.

RESULTS

In total, 50 of the 337 patients showed strong echogenic FT on US. Correlation with MRI data was possible in 40 of the 50 patients with strong echogenic FT. MRI scans of all 40 of these patients revealed the presence of fat in the FT. The maximum thickness in the strong echogenic area of the FT lipomas of these 40 patients was 1.7 ± 0.4 mm (range 1.2-2.5 mm), and the minimum thickness was 1.1 ± 0.2 mm (range 0.8-1.4 mm). Among the 40 infants, 13 (32%) had maximum FT thickness > 2 mm (mean thickness 2.2 ± 0.2 mm; range 2-2.5 mm) and 27 (68%) had echogenic FT < 2 mm thick (mean thickness 1.5 ± 0.2 mm; range 1-1.9 mm). The length of the echogenic segment on US was about 1.9-5.1 cm (mean length 3.4 ± 1.1 cm). All 40 patients showed FT lipoma without any associated abnormalities, such as cord tethering or low-lying conus. Among the total population of 337 patients, 30 (8.9%) showed borderline low-lying conus medullaris located at the L2-3 disc space or midpoint of the L3 vertebra. All 30 of these patients had borderline low-lying conus without other associated abnormalities. Filar cyst was noted in 36 of 337 patients (10.6%), without other associated abnormalities. No patient underwent surgery associated with a risk of neurological problems within a follow-up period of 10-37 months.

CONCLUSIONS

Although screening US in infants with simple sacral dimple yielded benign imaging findings, the presence of FT lipoma was common in these infants. Therefore, it is necessary to carefully observe changes in echogenicity during measurement of FT thickness on US. All FT lipomas were low risk and had no associated abnormalities, such as cord tethering or low-lying conus.

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.].

Clubfoot and Tethered Cord Syndrome: Results of Treatment With the Ponseti Method

BACKGROUND

The Ponseti technique has demonstrated high success rates worldwide for the treatment of idiopathic clubfoot. The purpose of this study was to determine whether clubfoot associated with tethered cord syndrome (TCS) was more resistant to Ponseti treatment than isolated clubfoot.

METHODS

An IRB-approved retrospective cohort study of subjects undergoing Ponseti treatment of clubfoot between 2002 and 2013 was conducted. Subjects with TCS were matched to subjects with isolated clubfoot (1:2) on the basis of laterality, date of birth, sex, and age at presentation. Subject demographics, number of casts placed (pretenotomy and posttenotomy), and recurrence data were collected. Generalized logistic regression and linear mixed model regression analyses were used to compare recurrence within 2 years of the initiation of casting and the log number of casts needed to achieve an acceptable correction, respectively.

RESULTS

Data from 24 subjects (16 isolated clubfeet, 8 with TCS) with clubfoot (12 bilateral, 12 unilateral) were analyzed. The isolated clubfoot group was the same age at presentation on average (21.9±4.7 d) as the TCS group (28.3±9.6 d) (P=0.55). The number of casts required to achieve an acceptable correction was 54% higher (95% CI, 7.8%-120.3%; P=0.0217) in the TCS group compared with the isolated clubfoot group. The cumulative crude incidence of deformity recurrence within the first 2 years after casting initiation was 8% in the isolated clubfoot group compared with 42% in the TCS group. The odds of deformity recurrence in the TCS group were 5.6 (95% CI, 0.7-45.2; P=0.1054) times the odds of deformity recurrence in the isolated clubfoot group. Furthermore, the incidence of deformity recurrence was higher among subjects who had a tethered cord release posttenotomy (56%, 5/9) as compared with pretenotomy (0%, 0/3).

CONCLUSION

Clubfoot associated with TCS required more casts to achieve an acceptable correction. Subjects with tethered cord were also at an increased risk of deformity recurrence compared with subjects with isolated clubfoot.

LEVEL OF EVIDENCE

Level II-retrospective prognostic study.

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.

Spinal cord ultrasonography of the newborn

Ultrasound represents the first-line survey for the assessment of spinal cord development abnormalities. In fact, within 6 months of life, the non-ossification of neuronal arcs provides an excellent acoustic window that allows a detailed depiction of the spinal canal, its content and of the surrounding soft tissues. Nevertheless, an accurate ultrasound examination requires a complete knowledge of the anatomy, the condition of normality, the frequent anatomical variants and the main pathologies involved. This review is intended to briefly summarize the US technique, the main clinical indication and the key notions that could help to properly perform this type of ultrasound examination.

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.

Ultrasonographic Evaluation of the Effect of Osteopathic Manipulative Treatment on Sacral Base Asymmetry

Context

Patients with low back pain (LBP) may receive osteopathic manipulative treatment (OMT) to resolve or manage their pain. The indication for OMT for patients with LBP is the presence of somatic dysfunction, diagnosed using palpatory examination. Because palpatory findings commonly have poor interexaminer reliability, the current study used ultrasonography (US) to establish pre-OMT and post-OMT musculoskeletal measurements of relative asymmetry between pelvic and sacral bony landmarks.

Objective

To document objective musculoskeletal changes that occur in response to OMT using US and to compare palpatory assessment of landmark asymmetry with US assessment.

Methods

Sixty men and women aged 20 to 55 years with at least 1 episode of LBP in the past 2 weeks were assigned to a seated control, walking control, or OMT group (20 participants per group). Participants received an initial, bilateral US measurement of the skin to posterior superior iliac spine (SPSIS), skin to sacral base position (SBP), and sacral sulcus depth (SSD). Participants in seated control and OMT groups received a palpatory assessment of SBP and SSD prior to initial US assessment. After assessment, the seated control group sat in a waiting room for 30 minutes, the walking control group walked for 5 minutes, and the OMT group received OMT to address sacral base asymmetry using predominantly direct techniques for a maximum of 20 minutes. Participants then received a second US assessment of the same structures.

Results

Body mass index (BMI) was correlated with SPSIS (r=0.5, P=.001) and SBP (r=0.6, P<.001). More participants in seated control (75%) and OMT (65%) groups had an increase in asymmetry from first to second US assessment for SPSIS compared with participants in the walking control group (35%, P=.05). No significant differences were found between groups for absolute asymmetry or total change in asymmetry (all P>.10). The κ was −0.1 (95% CI, −0.2 to 0.03) for SBP and −0.01 (95% CI, −0.1 to 0.1) for SSD.

Conclusion

Musculoskeletal changes in SPSIS and SBP measurements related to OMT could not be readily identified using US. The SPSIS and SBP measurements were dependent on BMI, which may have affected the accuracy of US to detect small changes in asymmetry. Qualitative palpatory assessments did not correlate with US measurements. Further study is needed to identify US measurements that demonstrate change with OMT. (ClinicalTrials.gov number NCT02820701)

A Cross-Sectional Assessment of Cutaneous Lumbosacral and Coccygeal Physical Examination Findings in a Healthy Newborn Population

Objective. The purpose of this study is to describe the range and frequency of cutaneous lumbosacral and coccygeal findings encountered during the newborn examination in a population of apparently healthy babies, to determine if the prevalence of these findings is associated with race/ethnicity, and to report the frequency of co-occurrence of low-risk cutaneous findings. Methods. Lumbosacral physical findings of 1121 infants were documented on well newborns at least 35 weeks or greater gestational age under the authors’ care. The overall frequency of each physical finding was tabulated in addition to determining whether frequencies varied by race/ethnicity. Co-occurrence of the most common physical findings was also examined. Results. Of 1096 infants included in the study, 24.8% had deviated or duplicated gluteal creases, 15.6% had dimples, and 24.7% had lumbosacral and/or coccygeal hairiness. All racial/ethnic groups had double to quadruple the risk of lumbosacral hair when compared with Caucasians. A total of 44.1% of study infants had lumbosacral/coccygeal slate-grey patches, which were least common in Caucasians. Seven infants had coccygeal skin tags, and 14 infants had lumbosacral vascular macules. Thirty-one percent had more than 1 cutaneous lumbosacral finding present, 24.8% had 2 findings, and 6.2% had 3 or more findings. Conclusion. Coccygeal dimples, increased lumbosacral and/or coccygeal hair, deviations and/or duplications of the gluteal crease, and lumbosacral slate-grey patches are common in healthy newborns and vary by race/ethnicity. Eleven percent of study infants had 2 or more low-risk cutaneous findings excluding slate-grey patches. Distinction between low-risk and common versus high-risk findings is important when deciding which patients need further evaluation.

Occult spinal dysraphisms in newborns with skin markers: role of ultrasonography and magnetic resonance imaging

PURPOSE

The purpose of this paper is to investigate occult spinal dysraphisms (OSD) using lumbar ultrasonography (LUS) in newborns presenting with specific skin markers or sacrococcygeal dimple.

METHOD

From 2012 to 2015, we performed LUS in newborns with cutaneous stigmata and/or sacroccygeal dimple. Magnetic resonance imaging (MRI) was performed in all patients with abnormal ultrasound or features of neurological involvement in order to detect spinal lesions.

RESULTS

We prospectively evaluated 475 newborns who presented cutaneous stigmata performing LUS during their 4 weeks of life though 439 completed the study. All patients had a follow-up of almost 12 months. Of these, 39 presented abnormal ultrasonography and underwent MRI. In this group, spinal dysraphism was confirmed in 12 patients. When considering skin markers, dermal sinus correlated with higher risk of spinal cord lesions, on the other hand the presence of simple sacral dimple alone denoted a very low risk of occult spinal dysraphism. The simultaneous presence of more skin markers and/or the presence of lumbar ultrasonography abnormality regarding the level of the conus, pulsatility, and the position of the cord, thickness of the filum terminale, or the presence of an intratecal mass, lipoma, or dermal sinus tract indicated the necessity to perform MRI in order to detect spinal cord abnormalities because of higher risk of spinal lesions.

CONCLUSION

LUS in newborns with specific skin markers is a valid method to select patients in which MRI can be performed to detect OSD. The presence of a simple sacral dimple alone is a negligible marker for occult neural pathology while the presence of isolated dermal sinus or more than one cutaneous marker could be considered indicative of higher risk of spinal dysraphism.

Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society

AIMS

As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Children's Continence Society (ICCS) recommendations for diagnosis and treatment of OSD.

METHODS

Guidelines were formulated based on analysis of pertinent literature and consensus among authors. This document was vetted by the multidisciplinary members of the ICCS via its website before submission for peer review publication.

RESULTS

The more frequent diagnosis of OSD is associated with increased operative intervention. Spinal cord untethering (SCU) has a highly variable risk profile, largely dependent on the specific form of OSD. Progressive neurological deterioration attributed to "tethered cord" may occur, with or without surgery, in selected forms of OSD whereas other cohorts do well.

CONCLUSION

Infants with classic cutaneous markers of OSD, with progressive neurologic, skeletal, and/or urologic findings, present no diagnostic or therapeutic dilemma: they routinely undergo MRI and SCU. Conversely, in asymptomatic patients or those with fixed, minor abnormalities, the risk profile of these OSD cohorts should be carefully considered before SCU is performed. Irrespective of whether or not SCU is performed, patients at risk for progression should be followed carefully throughout childhood and adolescence by a multidisciplinary team.

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.

Pediatric Spinal Ultrasound: Neonatal and Intraoperative Applications

The purpose of this article is to review the use of ultrasound as a screening tool for spinal diseases in neonates and infants and its intraoperative value in selected pediatric neurosurgical disorders. A review of spinal embryology followed by a description of common spinal diseases in neonates assessed with ultrasound is presented. Indications for spinal ultrasound in neonates, commonly identified conditions, and the importance of magnetic resonance imaging in selected cases are emphasized. Additionally, the use of ultrasound in selected neurosurgical spinal diseases in pediatric patients is presented with magnetic resonance imaging and intraoperative correlation. Technique, limitations, and pitfalls are discussed.

Use of magnetic resonance imaging to detect occult spinal dysraphism in infants

OBJECTIVE Cutaneous stigmata or congenital anomalies often prompt screening for occult spinal dysraphism (OSD) in asymptomatic infants. While a number of studies have examined the results of ultrasonography (US) screening, less is known about the findings when MRI is used as the primary imaging modality. The object of this study was to assess the results of MRI screening for OSD in infants. METHODS The authors undertook a retrospective review of all infants who had undergone MRI of the lumbar spine to screen for OSD over a 6-year period (September 2006-September 2012). All images had been obtained on modern MRI scanners using sequences optimized to detect OSD, which was defined as any fibrolipoma of the filum terminale (FFT), a conus medullaris ending at or below the L2-3 disc space, as well as more complex lesions such as lipomyelomeningocele (LMM). RESULTS Five hundred twenty-two patients with a mean age of 6.2 months at imaging were included in the study. Indications for imaging included isolated dimple in 235 patients (45%), asymmetrically deviated gluteal cleft in 43 (8%), symmetrically deviated (Y-shaped) gluteal cleft in 38 (7%), hemangioma in 28 (5%), other isolated cutaneous stigmata (subcutaneous lipoma, vestigial tail, hairy patch, and dysplastic skin) in 31 (6%), several of the above stigmata in 97 (18%), and congenital anomalies in 50 (10%). Twenty-three percent (122 patients) of the study population had OSD. Lesions in 19% of these 122 patients were complex OSD consisting of LMM, dermal sinus tract extending to the thecal sac, and lipomeningocele. The majority of OSD lesions (99 patients [81%]) were filar abnormalities, a group including FFT and low-lying conus. The rate of OSD ranged from 12% for patients with asymmetrically deviated gluteal crease to 55% for those with other isolated cutaneous stigmata. Isolated midline dimple was the most common indication for imaging. Among this group, 20% (46 of 235) had OSD. There was no difference in the rate of OSD based on dimple location. Those with OSD had a mean dimple position of 15 mm (SD 11.8) above the coccyx. Those without OSD had a mean dimple position of 12.2 mm (SD 19) above the coccyx (p = 0.25). CONCLUSIONS The prevalence of OSD identified with modern high-resolution MRI screening is significantly higher than that reported with US screening, particularly in patients with dimples. The majority of OSD lesions identified are FFT and low conus. The clinical significance of such lesions remains unclear.

Screening for Spinal Dysraphisms in Newborns With Sacral Dimples

Sacral dimples are common physical examination findings among newborns and are rarely associated with spinal dysraphism. Screening ultrasonography for simple sacral dimples in the absence of other physical findings leads to unnecessary health care costs and undue stress on families. This study was a retrospective chart review of infants with a sacral dimple on examination who underwent spinal ultrasonography in the first week of life. The documented indication for ultrasonography was compared to standard guidelines. Among 151 infants in the study, 80% had a normal spinal ultrasound. Of infants with abnormal ultrasonography, 7 (5%) had abnormal spinal magnetic resonance imaging and 2 infants (1%) required neurosurgical intervention. Our study revealed that nearly one-third of infants who underwent spinal ultrasonography had a simple sacral dimple and low likelihood of spinal dysraphism according to existing guidelines. Among patients who underwent spinal ultrasonography in accordance with guidelines, only a small percentage required neurosurgical intervention indicating that guidelines may need to be revised. Larger studies involving multiple centers are necessary to assess this need.

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

Primary care providers commonly obtain spine ultrasounds for neonates with simple sacral dimples due to perceived concerns about underlying spinal dysraphism, despite a lack of scientific evidence. Nine papers addressing routine spine ultrasounds for children with sacral dimples showed that 3.4% of the 5166 patients had abnormal spine ultrasounds, compared with the 4.8% reported by another study for children without sacral dimples. Most of the abnormal findings in patients with sacral dimples were of no clinical significance.

CONCLUSION

Sacral dimples do not predict underlying spinal cord malformations, and spine ultrasounds should not be performed for neonates with simple sacral dimples.

[Sacral dimple: What form of management is best?]

A sacral dimple measuring less than 5mm, within 25mm of the anus on the median line, with no other cutaneous anomaly, does not require any complementary examination. Parents can be reassured. However, any cutaneous depression in the sacrolumbar region not respecting these criteria must be considered as an occult dysraphism until proved otherwise. A medullary ultrasound examination and a consultation with a specialist (pediatric neurosurgeon) are necessary. The dermic sinus is the main differential diagnosis, with favorable outcome in case of early treatment before any infectious complication arises. Conversely, the risk of permanent sequelae is high if neglected or in case of late diagnosis.

Optimal Filum Terminale Thickness Cutoff Value on Sonography for Lipoma Screening in Young Children

OBJECTIVES

The purpose of this study was to evaluate the normal thickness of the filum terminale on sonography and suggest an optimal cutoff value for filum terminale lipoma screening in young children.

METHODS

We retrospectively reviewed lumbosacral sonograms and magnetic resonance images from children younger than 36 months that were obtained between January 2013 and June 2014. The filum terminale thickness on sonography and the presence of fat in the filum terminale on magnetic resonance imaging were evaluated.

RESULTS

From 111 children (mean age ± SD, 3.6 ± 3.0 months), 49 did not have abnormal lesions (normal group), and 62 had fat infiltration in the filum terminale (lipoma group). The filum terminale was thicker in the lipoma group than the normal group (1.5 ± 0.5 versus 0.9 ± 0.2 mm; P < .001). Filum terminale thickness also showed significance in a multivariable analysis with sex and age (odds ratio per 0.1-mm unit, 2.754; P < .001) and in propensity score matching for age (P < .001). The optimal cutoff value for filum terminale lipoma screening was 1.1 mm, with 94% sensitivity and 86% specificity.

CONCLUSIONS

The conventional cutoff value of 2 mm for a thickened filum terminale on sonography can be too thick. We suggest an optimal cutoff value of 1.1 mm for lipoma screening in young children.