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Kawamoto Y, Harada A, Ikura Y, Fujinaga T, Utsunomiya H. Limited dorsal myeloschisis without extradural stalk continuity to coexisting congenital dermal sinus. Childs Nerv Syst 2023; 39:511-515. [PMID: 35939129 DOI: 10.1007/s00381-022-05631-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/19/2022] [Indexed: 11/03/2022]
Abstract
Limited dorsal myeloschisis (LDM) is characterized by a fibroneural tethering stalk linking the skin lesion to the underlying spinal cord. LDM without an extradural stalk is rare. A full-term boy was noted at birth to have a dimple in the upper back (dorsal skin of the lower thoracic region). Computed tomographic scan showed spina bifida at the T9-12 vertebral level and osteochondral tissue at the T10 level. Magnetic resonance imaging (MRI) demonstrated a tiny dorsal lipoma at the T8 vertebral level, but the intradural tethering tract was not apparent. At 18 days of age, the congenital dermal sinus (CDS) tract started from the dimple and terminated at the osteochondral tissue, without continuity of the dura mater, and the osteochondral tissues were resected. At age 2 years 8 months, he developed spastic paresis of the right foot. On MRI, the tethering tract from the dorsal lipoma became apparent. During the second surgery at age 2 years 11 months, the intradural stalk started from the dorsal lipoma and joined the inner surface of the dura mater was untethering from the cord. Postoperatively, right spastic paresis was improved. Histological examination of the intradural stalk revealed the distribution of S100-immunopositive peripheral nerve fibers, which is one of the histopathological hallmarks of LDM. We speculated that the extradural stalk with coexisting CDS originally linked from the skin lesion subsequently regressed and was replaced by fibroadipose tissue with osteochondral tissue migration. Intradural exploration should always be seriously considered in these disorders of persisting neurocutaneous connection.
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Affiliation(s)
- Yuki Kawamoto
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Takatsuki, Japan
| | - Atsuko Harada
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Takatsuki, Japan.
| | - Yoshihiro Ikura
- Department of Pathology, Takatsuki General Hospital, Takatsuki, Japan
| | - Takahiro Fujinaga
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Takatsuki, Japan
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Shimogawa T, Mukae N, Kanata A, Tsukamoto H, Murakami N, Kurogi A, Shono T, Suzuki SO, Morioka T. Spinal cord deformity with aggravation of tethering in saccular limited dorsal myeloschisis during the first 2 months of life. Surg Neurol Int 2021; 12:476. [PMID: 34621591 PMCID: PMC8492443 DOI: 10.25259/sni_517_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/01/2021] [Indexed: 11/04/2022] Open
Abstract
Background Although the optimal timing of prophylactic untethering surgery for limited dorsal myeloschisis (LDM) with intact or subtle neurological findings diagnosed at birth remains undetermined, intentional delayed surgery is commonly used for flat and tail-like LDM. Conversely, for saccular LDM, early surgery is indicated during the postnatal period because it prevents rupture of the sac. We treated a saccular LDM patient, in whom intentional delayed surgery was selected because the sac was thickly covered with normal skin. We describe the clinical course of the case and discuss the optimal timing of the surgery. Case Description The patient had a dorsal midline sac in the upper lumbar region. Initial magnetic resonance imaging (MRI) after birth revealed a tethering tract that began at the dome of the sac and joined the lumbar cord. Dorsal bending of the cord at the stalk-cord union and invagination of the cord into the sac were noted. At 2 months, he was neurologically normal; however, the second MRI examination revealed that the cord tethering was aggravated. The cord was markedly displaced dorsally and to the left, with deviation of the cord to the sac out of the spinal canal. Following untethering surgery, the spinal cord deformity markedly improved. Conclusion Early surgery may be recommended for saccular LDM when tethering is present, including dorsal bending of the cord at the stalk-cord union and invagination of the cord into the sac observed on detailed MRI examination, even if the sac has no risk of rupture.
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Affiliation(s)
- Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Kanata
- Department of Neurosurgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Haruhisa Tsukamoto
- Department of Neurosurgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ai Kurogi
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Tadahisa Shono
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
| | | | - Takato Morioka
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
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KUROGI A, MORIOKA T, MURAKAMI N, SHIMOGAWA T, MUKAE N, MATSUO Y, IMAMOTO N, TATEISHI Y, SUZUKI SO. Saccular Limited Dorsal Myeloschisis with Spinal Cord Deviation out of the Spinal Canal to the Sac. NMC Case Rep J 2021; 8:739-746. [PMID: 35079542 PMCID: PMC8769447 DOI: 10.2176/nmccrj.cr.2021-0168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/19/2021] [Indexed: 12/04/2022] Open
Abstract
Saccular limited dorsal myeloschisis (LDM) is characterized by a fibroneural stalk linking the saccular skin lesion to the underlying spinal cord. Since untethering surgery during the early postnatal period is often indicated to prevent sac rupture, saccular LDM should be distinguished from myelomeningocele (MMC) during the perinatal period. We treated two patients with the spinal cord deviation from the spinal canal to the sac, which mimicked a prolapse of the neural placode into the MMC sac. In patient 1, pre- and postnatal magnetic resonance imaging (MRI) revealed that the spinal cord was strongly tethered to the thick stalk. During surgery, the dorsally bent cord and stalk were united, and the border between these two was determined with intraoperative neurophysiological mapping (IONM). In patient 2, the spinal cord was tethered to two slender stalks close to each other, which was visible with the combined use of sagittal and axial postnatal three-dimensional heavily T2-weighted imaging (3D-hT2WI). The preoperative MRI hallmark of saccular LDM is the visualization of a stalk that links the bending cord and sac. Complete untethering surgery to return the cord into the spinal canal and correct its dorsal bending is recommended.
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Affiliation(s)
- Ai KUROGI
- Department of Neurosurgery, Fukuoka Children’s Hospital, Fukuoka, Fukuoka, Japan
| | - Takato MORIOKA
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Fukuoka, Japan
| | - Nobuya MURAKAMI
- Department of Neurosurgery, Fukuoka Children’s Hospital, Fukuoka, Fukuoka, Japan
| | - Takafumi SHIMOGAWA
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Nobutaka MUKAE
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Yoshihiro MATSUO
- Department of Neurosurgery, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
| | - Naoyuki IMAMOTO
- Department of Neurosurgery, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
| | - Yuki TATEISHI
- Department of Pathology, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
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Soon WC, Das JM, Baig A, Gallo P, Rodrigues D, Lo WB. Atlantoaxial limited dorsal myeloschisis: A report of two cases and review of literature. BRAIN AND SPINE 2021; 1:100298. [PMID: 36247398 PMCID: PMC9560655 DOI: 10.1016/j.bas.2021.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/29/2021] [Accepted: 09/13/2021] [Indexed: 11/05/2022]
Abstract
Introduction Limited dorsal myeloschisis (LDM) is a rare form of spinal dysraphism that is characterised by a distinctive fibroneural stalk connecting the spinal cord to the overlying skin lesion. The skin lesions associated with LDM can appear benign clinically and careful evaluation with an MRI scan is essential for diagnosing LDM and to differentiate this entity from other forms of spinal dysraphism and benign causes of skin lesions. Research question There is a lack of reported atlantoaxial LDM in the literature. We sought to report the clinical presentation, radiological features and surgical management of the first two reported atlantoaxial LDM. Material and methods Clinical findings and radiological images of the two cases of atlantoaxial LDM that underwent surgical intervention at our institution were retrieved from the medical notes, operative records and imaging system. Results Both cases of atlantoaxial LDM (C0-1 and C1-2 respectively) underwent successful resection of the overlying cutaneous lesions and stalks to release the tethered spinal cords. Discussion The surgical management of LDM have been associated with good outcomes and consists of resecting the fibroneural stalk close to the underlying cord, releasing the tethered spinal cord and removing the overlying cutaneous lesion. Conclusion These are the first two reported cases of atlantoaxial LDM in the literature. We aim to raise awareness of this pathological entity and highlight the importance of establishing the correct diagnosis to guide definitive management, and report the favourable neurological outcome in these cases despite the rostral location. Limited dorsal myeloschisis is a rare form of closed spinal dysraphism. These are the first two reported cases of atlantoaxial limited dorsal myeloschisis. Favourable surgical outcomes can be achieved despite the rostral location. Dorsal midline cutaneous lesions should be investigated further with MRI scan. The fibroneural stalk connects the overlying cutaneous lesion to the spinal cord.
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Abe K, Mukae N, Morioka T, Shimogawa T, Suzuki SO, Mizoguchi M. Tail-like cutaneous appendage at the upper thoracic region with a continuous stalk of limited dorsal myeloschisis. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Murakami N, Morioka T, Suzuki SO, Mukae N, Shimogawa T, Matsuo Y, Sasaguri T, Mizoguchi M. Clinicopathological findings of limited dorsal myeloschisis associated with spinal lipoma of dorsal-type. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Morioka T, Murakami N, Yanagida H, Yamaguchi T, Noguchi Y, Takahata Y, Tsukamoto A, Suzuki SO. Terminal syringomyelia associated with lumbar limited dorsal myeloschisis. Childs Nerv Syst 2020; 36:819-826. [PMID: 31317225 DOI: 10.1007/s00381-019-04297-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/02/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Limited dorsal myeloschisis (LDM) is characterized by a fibroneural tethering stalk linking the skin lesion to the underlying spinal cord. Terminal syringomyelia, which is located at the lower third of the cord, is often associated with a tethered cord caused by various spinal dysraphisms; however, terminal syringomyelia has not been documented in LDM. The purpose of this study was to clarify the pathophysiological mechanisms of syringomyelia in LDM. METHODS In our 16 patients with lumbar LDM, three patients had terminal syringomyelia. We retrospectively analyzed the clinical, neuroradiological, intraoperative, and histopathological findings for these patients, with particular attention to the clinical course of the syrinx. RESULTS Patient 1 had a saccular skin lesion and patients 2 and 3 had flat lesions. In all patients, the syringomyelic cavity was located in the lower thoracolumbar cord, immediately rostral to the stalk-cord attachment at the lumbar level. The caudal pole of the syrinx extended to the thickened stalk at the attachment instead of at the caudal cord. Patient 3 had another syrinx in the stalk itself. The longitudinal axis of the syrinx and central canal coincided with the traveling angle of the LDM stalk at the stalk-cord attachment. In patient 1, histology revealed an ependyma-lined central canal in both the LDM stalk and meningocele sac. Patients 1 and 2 underwent syringostomy, but long-term effects were not obtained. Preoperative spontaneous resolution occurred in patient 3. CONCLUSIONS The histological findings in patient 1 supported the idea that segmental myelocystocele is involved in the development of saccular LDM. The hydromyelic central canal herniates and distends the stalk, resulting in the formation of the myelocystocele. It is possible that the hydromyelic central canal also distends the stalk of flat LDM lesions. The syrinx in patient 3 differed from that in patients 1 and 2, in that the syrinx resolved spontaneously. Further studies are needed to clarify the outcomes of syrinxes associated with LDM stalks.
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Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan.
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Haruhisa Yanagida
- Department of Orthopedics and Spine Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Toru Yamaguchi
- Department of Orthopedics and Spine Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Yushi Noguchi
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Yasushi Takahata
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ayumi Tsukamoto
- Department of Plastic Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Morioka T, Murakami N, Suzuki SO, Takada A, Tajiri S, Shimogawa T, Mukae N, Iihara K. Neurosurgical Pathology and Management of Limited Dorsal Myeloschisis Associated with Congenital Dermal Sinus in Infancy. Pediatr Neurosurg 2020; 55:113-125. [PMID: 32615563 DOI: 10.1159/000507867] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Because of the shared origin of limited dorsal myeloschisis (LDM) and congenital dermal sinus (CDS), CDS elements may be found within the fibroneural LDM stalk. When part of the CDS invested in the intradural stalk is left during untethering surgery, inclusion tumors such as dermoid cysts may develop. However, the most appropriate surgical strategy for LDM with CDS is still under debate. METHODS Of 19 patients with LDM, 3 (15.8%) had histologically verified CDS elements. We retrospectively analyzed the clinicopathological findings of these patients. RESULTS In patient 1, the entire stalk including a tiny dermoid cyst at the intradural stalk could be resected through two-level laminectomy during untethering at 6 months of age. In patients 2 and 3, the stalk appeared to be a typical LDM stalk during the initial surgery at 18 and 7 days, respectively; however, CDS was histologically diagnosed in the proximal severed end of the stalk. Postoperative three-dimensional heavily T2-weighted imaging demonstrated spherical enlargement of the remnant stalk, and the entire length of the remnant stalk including newly developed dermoid was resected during the second surgery at 3 years 11 months and 11 months, respectively. Histopathologically, glial fibrillary acidic protein-immunopositive neuroglial tissues and CDS elements were mainly located at the proximal and distal sites of the stalk, respectively, supporting the "dragging down and pulling up" theory. In patients 2 and 3, however, the proximal head of the dermoid cyst passed the distal head of the neuroglial tissues and located at the stalk-cord attachment. CONCLUSION Surgeons should be aware of the approximately 10% possibility of the coexistence of CDS when managing infant LDM. However, the recommendation for excision of the entire length of the LDM stalk in all patients should be more carefully made because such a strategy may result in an unnecessary extent of laminotomy/laminectomy for most patients with pure LDM. However, once the postoperative histological examination reveals coexistence of CDS in the resected proximal part of the stalk, the entire length of the remnant stalk should be excised as soon as possible.
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Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan,
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akira Takada
- Department of Neurosurgery, Kumamoto City Hospital, Kumamoto, Japan
| | - Seiji Tajiri
- Department of Neurosurgery, Kumamoto City Hospital, Kumamoto, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Morioka T, Murakami N, Ichiyama M, Kusuda T, Suzuki SO. Congenital Dermal Sinus Elements in Each Tethering Stalk of Coexisting Thoracic Limited Dorsal Myeloschisis and Retained Medullary Cord. Pediatr Neurosurg 2020; 55:380-387. [PMID: 33271568 DOI: 10.1159/000511876] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 09/19/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The embryogenesis of limited dorsal myeloschisis (LDM) likely involves impaired disjunction between the cutaneous and neural ectoderms during primary neurulation. Because LDM and congenital dermal sinus (CDS) have a shared origin in this regard, CDS elements can be found in the LDM stalk. Retained medullary cord (RMC) is a closed spinal dysraphism involving a robust, elongated, cord-like structure extending from the conus medullaris to the dural cul-de-sac. Because the RMC is assumed to be caused by impaired secondary neurulation, concurrent RMC and CDS cannot be explained embryologically. In the present article, we report a case in which CDS elements were noted in each tethering stalk of a coexisting LDM and RMC. CASE PRESENTATION A 2.5-month-old boy with left clubfoot and frequent urinary and fecal leakage had 2 tethering tracts. The upper tract, which ran from the thoracic tail-like cutaneous appendage, had CDS elements in the extradural stalk and a tiny dermoid cyst in the intradural stalk immediately after the dural entry. In the lower tract, which ran from the lumbosacral dimple, the CDS as an extradural stalk continued to the RMC at the dural cul-de-sac. Both stalks were entirely resected through skip laminotomy/laminectomy at 1 stage to untether the cord and resect the CDS elements. CONCLUSION Surgeons should be aware that CDS elements, in addition to LDM, may coexist with RMC that extends out to the extradural space.
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Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan, .,Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan,
| | - Nobuya Murakami
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Masako Ichiyama
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takeshi Kusuda
- Department of Neonatology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Psychiatry, Shourai Hospital, Saga, Japan
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