A tail of sacral agenesis: delayed presentation of meningocele in sacral agenesis

Incidental Sacral Meningocele in an Elderly Patient Diagnosed After Epidermal Inclusion Cyst Removal: A Case Report

A meningocele is a congenital neural tube defect, and the majority of the meningocele cases are identified perinatally. We present the case of a 67-year-old patient with a sacral meningocele undiagnosed until the removal of a symptomatic epidermal inclusion cyst adjacent to it. Cerebrospinal fluid leakage occurred due to an incision in an undiagnosed meningocele adjacent to the epidermal inclusion cyst. Repair of the cerebrospinal fluid leakage was performed successfully without any deficit. The present case underscores the importance of considering a meningocele as a differential diagnosis for a mass occurring in the midline of the back at any age.

Impact of Rigid Fixation of the Pubic Symphysis for Spinopelvic Fixation in Two Cases of Lumbosacral Agenesis

Introduction

In patients with lumbosacral agenesis (SA), Renshaw type III or IV, lumbosacral instability is the primary cause of major clinical complications. Although they are usually treated with spinopelvic fusion, nonunion at the spinopelvic junction is a major complication due to the congenital sacropelvic abnormalities. The purpose of this study was to evaluate whether a combination of lumbosacral fixation and rigid fixation at the pubic symphysis could lead to postoperative bone union in patients with SA (Renshaw type III).

Methods

Retrospective case series study. We present the cases of two patients with SA, Renshaw type III, who were surgically treated by lumbosacral fusion using a posterior approach, and they exhibited nonunion at the lumbosacral junction.

Results

Case 1. A 10-year-old male underwent T8-S posterior fixation followed by multiple augmentations using allografts at the lumbosacral junction for delayed union. All additional procedures with bone graft using a posterior approach failed to achieve bone union; however, additional rigid fixation at the pubic symphysis resulted in a successful lumbosacral bone union.

Case 2. A 6-year-old male underwent vertical expandable prosthetic titanium rib (VEPTR) surgery with multiple rod extension procedures. Subsequently, at the age of 10 years, a combined two-stage anterior (L1-3) and posterior (T8-iliac) fixation with T9 hemivertebrectomy was performed. As a result of subsequent nonunion with screw loosening, additional rigid fixation at the pubic symphysis was performed 1 month after posterior fixation. Bone union was finally achieved 1 year after all the surgical interventions.

Conclusions

Rigid fixation at the pubic symphysis may play a significant role in achieving rigid bone union for unstable lumbopelvic connection, such as SA, Renshaw type III or IV.

Sacral agenesis combined with spinopelvic dissociation: A case report and literature review

INTRODUCTION

Sacral agenesis is a rare congenital disease with radiologic manifestation of sacrum deformity. Its clinical manifestations include spinopelvic instability due to sacroiliac joint deformity, spinal rotation, scoliosis, difficulties in walking, and claudication. Surgical intervention aims to prevent further deformity progression and to improve the patients' walking function. It is challenging to achieve solid arthrodesis for this congenital disease, and fusion failure could aggravate deformity.

CASE PRESENTATION

We retrospectively studied one case of a 12-year-old girl with sacral agenesis combined with spinopelvic dissociation and spinal scoliosis. She was presented with intermittent lumbosacral pain and worsening walking instability. We reconstructed the posterior pelvic ring through 1 iliac screw implanted in the bilateral posterior superior iliac spine, and the preflexed connecting rod was tightly locked with bilateral screws through the opening at the right spinal process of S2. With this method, bilateral ilia and sacrum were integrated and hemipelvic floating could be corrected. Bone fusion was achieved between the bilateral ilia and the sacrum.

CONCLUSION

Ilium-sacrum-ilium internal fixation and fusion for treating sacral agenesis combined with spinopelvic dissociation could achieve sacroiliac joint fusion. It is easy to perform and could cause little trauma while preserving the lumbar motion segment, which will provide new insight for treating sacral agenesis.

Symptomatic lower urinary tract dysfunction in sacral agenesis: Potentially high risk?

Introduction

Sacral agenesis (SA) is a caudal regression anomaly that can cause neurogenic bladder but is not generally recognized as high risk. We studied the clinical presentation, upper urinary tract, bone and spine abnormalities, and urodynamic findings in patients with SA and compared them with related high-risk conditions, anorectal malformation (ARM), and cloacal malformation.

Materials and Methods

Patient records between May 2011 and December 2015 were identified and grouped into isolated SA without an overt anomaly (Group I), SA with overt caudal regression anomalies (Group II), and ARM or cloacal malformation without the SA (Group III). Distribution of clinical and urodynamic findings and factors associated with reduced eGFR were tested with rank sum test, t-test, and unadjusted odds (P < 0.05 significant) using R statistical program (version 3.1.3).

Results

Of 605 neurogenic bladder patients treated in the study period, 39 fulfilled the inclusion criteria. 12 were Group I, 5 Group II, and 22 Group III. Long-standing lower urinary symptoms were noted in all SA patients. Group I patients were older (14.5 years vs. 6 years and 5 years for II and III). Patients with SA (Group I and II) had poor compliance (6.7 ml/cmH₂O, interquartile range [IQR] 4-13.6 ml/cmH₂O), reduced age-adjusted bladder capacity (59%, IQR 22-85%), elevated end-fill pressure (22 cmH₂O, IQR 11-28 cmH₂O), hydronephrosis (88%), and reduction in eGFR (29%), all comparable to Group III. Most had Renshaw type II SA and tethered spinal cord rather than wedge-shaped termination. Limitations include small numbers and significant selection bias.

Conclusions

Symptomatic neurogenic bladder due to SA may cause renal damage similar to ARM but often eludes diagnosis.

Congenital meningocoele presenting in an adult

A 53-year-old male patient presented with low back pain radiating to both lower limbs for 2 years and urinary incontinence for 2 months. He had swelled over his lower back since birth. The neurological examination revealed a decreased perianal sensation. Local examination of the lumbar swelling showed a brilliantly transilluminant, cystic midline swelling in the lumbar area with underlying spina bifida. Magnetic resonance imaging revealed a low-lying conus at L3 level associated with spina bifida at L5 and a meningocoele sac. The patient underwent excision of the meningocoele and detethering of cord by extirpation of hypertrophied filum terminale. The patient had an immediate relief of his symptoms. At 3 month follow-up the lumbar wound had healed well, and there was a significant improvement in the perianal hypoesthesia. The adult presentation of a congenital meningocoele and spinal dysraphism is rare, especially in the fifth decade. The possible causes of this delayed presentation are analyzed, and the relevant literature on the subject is presented.