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Toms AS, Rai E, John NC, Panwar J. Use of ultrasound to estimate the prevalence of occult spinal dysraphism in children undergoing urogenital and anorectal surgeries: A cross-sectional study. J Anaesthesiol Clin Pharmacol 2024; 40:90-94. [PMID: 38666156 PMCID: PMC11042110 DOI: 10.4103/joacp.joacp_254_22] [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: 07/16/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 04/28/2024] Open
Abstract
Background and Aim The use of ultrasound has immensely increased the safety toward regional blocks and central venous access and has been considered as the standard of care for securing central access. The aim of this study is to estimate the prevalence of occult spinal dysraphism using ultrasound in children less than 2 years of age undergoing elective urogenital or anorectal surgery. Material and Methods The lumbosacral region of 159 American Society of Anesthesiologists (ASA) category I/II patients, posted for elective urogenital and anorectal surgery was scanned with ultrasound, prior to giving caudal block. Results The prevalence of occult spina bifida was 3% in our study. There was no statistically significant association of cutaneous marker with abnormal scan. Conclusion Prevalence of occult spina bifida was ten-times higher in our study than in the general population. Perioperative ultrasound screening of the lower spinal anatomy by anesthesiologist done prior to performing neuraxial block is worthwhile in ruling out occult spinal anomalies in high-risk children of occult spinal dysraphism.
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Affiliation(s)
- Ann Sumin Toms
- Asst. Professor, Department of Anaesthesiology, CMC Vellore, Tamil Nadu, India
| | - Ekta Rai
- Professor and Head, Department of Anaesthesiology, CMC Vellore, Tamil Nadu, India
| | - Novin Chacko John
- Senior Registrar, Department of Anaesthesiology, CMC Vellore, Tamil Nadu, India
| | - Jyoti Panwar
- Professor, Department of Radiology, CMC Vellore, Tamil Nadu, India
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Ren F, Bressler L, Pruitt L, Wang H, Liu L, Elston DM. Midline cutaneous anomalies of the craniospinal axis. J Am Acad Dermatol 2023; 89:1238-1244. [PMID: 37598328 DOI: 10.1016/j.jaad.2023.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/28/2023] [Accepted: 06/26/2023] [Indexed: 08/21/2023]
Abstract
Patients with midline cutaneous anomalies of the craniospinal axis can be indicative of underlying embryonic defects, such as neural tube defects. Lack of familiarity with these midline aberrant skin findings may lead to misdiagnosis and delayed treatment. In this review, midline cutaneous anomalies of the craniospinal axis including aplasia cutis congenita, cranial and spinal dysraphism, and other developmental anomalies are explored in detail with emphasis on cutaneous clues to the diagnosis and appropriate workup.
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Affiliation(s)
- Faliang Ren
- Department of Dermatology, Children's Hospital of Chongqing Medical University, Chongqing, China; Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Lindsey Bressler
- Department of Dermatology & Dermatological Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Laura Pruitt
- Department of Dermatology & Dermatological Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Hua Wang
- Department of Dermatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Liu
- Department of Dermatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Dirk M Elston
- Department of Dermatology & Dermatological Surgery, Medical University of South Carolina, Charleston, South Carolina
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Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change. ANTHROPOLOGICAL REVIEW 2022. [DOI: 10.18778/1898-6773.85.2.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Neonatal and Infant Spine. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:E9-E15. [PMID: 34792215 DOI: 10.1002/jum.15875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 06/13/2023]
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Rees MA, Squires JH, Coley BD, Hoehne B, Ho ML. Ultrasound of congenital spine anomalies. Pediatr Radiol 2021; 51:2442-2457. [PMID: 34532816 DOI: 10.1007/s00247-021-05178-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/07/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Mitchell A Rees
- Department of Radiology, Nationwide Children's Hospital,, ED Building, 4th Floor, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Judy H Squires
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Brian D Coley
- Department of Radiology,, Cincinnati Children's Hospital Medical Cente,, Cincinnati, OH, USA.,Department of Radiology,, University of Cincinnati College of Medicine,, Cincinnati, OH, USA
| | - Brad Hoehne
- Department of Radiology, Nationwide Children's Hospital,, ED Building, 4th Floor, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Mai-Lan Ho
- Department of Radiology, Nationwide Children's Hospital,, ED Building, 4th Floor, 700 Children's Drive, Columbus, OH, 43205, USA
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6
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Svokos K, Batista-Silverman L, Graber SJ, O'Neill BR, Handler MH. International survey on the management of lumbosacral cutaneous stigmata in infants with suspected occult spinal dysraphism. J Neurosurg Pediatr 2021; 28:592-599. [PMID: 34479200 DOI: 10.3171/2021.5.peds2126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/21/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | - Sarah J Graber
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Brent R O'Neill
- 2Department of Neurosurgery, University of Colorado, Denver; and.,3Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Michael H Handler
- 2Department of Neurosurgery, University of Colorado, Denver; and.,3Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
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Resmi MR, Thappa DM, Chandrashekar L, Plakkal N, Ramesh A. A Hospital Based Cross Sectional Study of Midline Cutaneous Lesions in Neonates and its Association with Spinal Dysraphism Detected Using Ultrasound. Indian Dermatol Online J 2021; 12:408-411. [PMID: 34211906 PMCID: PMC8202487 DOI: 10.4103/idoj.idoj_748_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/26/2020] [Accepted: 01/25/2021] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- M R Resmi
- Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Devinder Mohan Thappa
- Department of Dermatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Laxmisha Chandrashekar
- Department of Dermatology and STD, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - A Ramesh
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Choi SJ, Yoon HM, Hwang JS, Suh CH, Jung AY, Cho YA, Lee JS. Incidence of Occult Spinal Dysraphism Among Infants With Cutaneous Stigmata and Proportion Managed With Neurosurgery: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e207221. [PMID: 32614421 PMCID: PMC7333023 DOI: 10.1001/jamanetworkopen.2020.7221] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Se Jin Choi
- Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Mang Yoon
- Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Sun Hwang
- Department of Radiology, Hallym University Medical Center, Dongtan Sacred Heart Hospital, Hwaseong, South Korea
| | - Chong Hyun Suh
- Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ah Young Jung
- Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young Ah Cho
- Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jin Seong Lee
- Research Institute of Radiology, Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Unveiling the tale of the tail: an illustration of spinal dysraphisms. Neurosurg Rev 2019; 44:97-114. [PMID: 31811517 DOI: 10.1007/s10143-019-01215-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/31/2019] [Accepted: 11/20/2019] [Indexed: 01/15/2023]
Abstract
Spinal dysraphism is an umbrella term describing herniation of meninges or neural elements through defective neural arch. They can be broadly categorized into open and closed types. MRI is the investigation of choice to study neural abnormalities and to assess the severity of hydrocephalus and Chiari malformation. Knowledge of the embryology of these disorders is valuable in correctly identifying the type of dysraphism. The aim of surgery is untethering and dural reconstruction. Accurate depiction of the abnormal anatomy in cases of spinal dysraphism is of utmost importance for surgical management of these patients. MRI makes this possible due to its excellent soft tissue contrast resolution and multiplanar capability, allowing the radiologist to evaluate the intricate details in small pediatric spinal structures. Imaging enlightens the surgeons about the status of spinal cord and other associated abnormalities and helps detect re-tethering in operated cases. Besides, antenatal surgery to repair myelomeningoceles has made detection of open dysraphisms on fetal MRI and antenatal ultrasound critical. The purpose of this review is to describe the development of spine, illustrate the myriad imaging features of open and closed spinal dysraphisms, and enlist the reporting points the operating surgeon seeks from the radiologist.
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Cho HH, Lee SM, You SK. Optimal Timing of Spinal Ultrasound Evaluations for Sacral Dimples in Neonates: Earlier May Not Be Better. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1241-1247. [PMID: 30208241 DOI: 10.1002/jum.14803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 07/31/2018] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Hyun-Hae Cho
- Department of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - So Mi Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Sun Kyoung You
- Department of Radiology, Chungnam National University Hospital, Daejeon, Korea
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11
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Choi JH, Lee T, Kwon HH, You SK, Kang JW. Outcome of ultrasonographic imaging in infants with sacral dimple. KOREAN JOURNAL OF PEDIATRICS 2018; 61:194-199. [PMID: 29963103 PMCID: PMC6021363 DOI: 10.3345/kjp.2018.61.6.194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/25/2017] [Accepted: 10/31/2017] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Jin Hyuk Choi
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Taekwan Lee
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyeok Hee Kwon
- Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Kyoung You
- Department of Radiology, Chungnam National University Hospital, Daejeon, Korea
| | - Joon Won Kang
- Department of Pediatrics, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea.,Department of Medical Science, Chungnam National University School of Medicine, Daejeon, Korea.,Brain Research Institute, Chungnam National University School of Medicine, Daejeon, Korea
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Ausili E, Maresca G, Massimi L, Morgante L, Romagnoli C, Rendeli C. Occult spinal dysraphisms in newborns with skin markers: role of ultrasonography and magnetic resonance imaging. Childs Nerv Syst 2018; 34:285-291. [PMID: 29075839 DOI: 10.1007/s00381-017-3638-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- E Ausili
- Spina Bifida Center, Women's and Infant Health Sciences, A. Gemelli Policlinic, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy.
| | - G Maresca
- Spina Bifida Center, Women's and Infant Health Sciences, A. Gemelli Policlinic, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - L Massimi
- Neurosurgery Department, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - L Morgante
- Spina Bifida Center, Women's and Infant Health Sciences, A. Gemelli Policlinic, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - C Romagnoli
- Spina Bifida Center, Women's and Infant Health Sciences, A. Gemelli Policlinic, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
| | - C Rendeli
- Spina Bifida Center, Women's and Infant Health Sciences, A. Gemelli Policlinic, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168, Rome, Italy
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13
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Kwon M, Je BK, Hong D, Choi BM. Ultrasonographic features of the normal filum terminale. Ultrasonography 2017; 37:129-133. [PMID: 28736427 PMCID: PMC5885475 DOI: 10.14366/usg.17032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/08/2017] [Accepted: 06/08/2017] [Indexed: 11/21/2022] Open
Abstract
Purpose The filum terminale (FT) is a fibrous band that connects the conus medullaris to the posterior body of the coccyx. Considering the advances of ultrasonography (US) technology and improvements in the resolution of US images, we aimed to re-establish the US features of the normal FT in infants younger than 6 months of age. Methods We retrospectively reviewed 30 spinal US scans, stored as video clips. The internal structure of the FT and the marginal echogenicity of the FT were assessed, and transverse and longitudinal US were compared. Results On US, a central echogenic line was defined in 18 (60%) normal FTs; however, there was no visible internal structure in 12 cases (40%). The marginal echogenicity of the FT was hyperechoic in eight cases (27%) in comparison with the cauda equina and was isoechoic in 22 cases (73%). In differentiating the normal FT from the surrounding nerve roots, transverse US was superior in 18 cases (60%), while longitudinal US was superior in two cases (7%). Conclusion On US, the central canal of the FT was defined in 60% of normal FTs. Hyperechoic marginal echogenicity and the use of transverse US were helpful in distinguishing the normal FT from the nerve roots of the cauda equina.
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Affiliation(s)
- Myoungae Kwon
- Department of Radiology, Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Bo-Kyung Je
- Department of Radiology, Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Doran Hong
- Department of Radiology, Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Byung Min Choi
- Department of Pediatrics, Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Alvarado E, Leach J, Caré M, Mangano F, O Hara S. Pediatric Spinal Ultrasound: Neonatal and Intraoperative Applications. Semin Ultrasound CT MR 2017; 38:126-142. [PMID: 28347416 DOI: 10.1053/j.sult.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Enrique Alvarado
- Department of Radiology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH
| | - James Leach
- Department of Radiology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH.
| | - Marguerite Caré
- Department of Radiology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH
| | - Francesco Mangano
- Department of Neurosurgery, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH
| | - Sara O Hara
- Department of Radiology, Cincinnati Children׳s Hospital Medical Center, Cincinnati, OH
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15
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O'Neill BR, Gallegos D, Herron A, Palmer C, Stence NV, Hankinson TC, Corbett Wilkinson C, Handler MH. Use of magnetic resonance imaging to detect occult spinal dysraphism in infants. J Neurosurg Pediatr 2017; 19:217-226. [PMID: 27911245 DOI: 10.3171/2016.8.peds16128] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Claire Palmer
- Pediatrics, Children's Hospital Colorado, Aurora; and
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16
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Wilson P, Hayes E, Barber A, Lohr J. Screening for Spinal Dysraphisms in Newborns With Sacral Dimples. Clin Pediatr (Phila) 2016; 55:1064-70. [PMID: 27554766 DOI: 10.1177/0009922816664061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Peyton Wilson
- University of North Carolina, Chapel Hill, NC, USA North Carolina Children's Hospital, Chapel Hill, NC, USA
| | - Erin Hayes
- North Carolina Children's Hospital, Chapel Hill, NC, USA
| | | | - Jacob Lohr
- University of North Carolina, Chapel Hill, NC, USA
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17
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Albert GW. Spine ultrasounds should not be routinely performed for patients with simple sacral dimples. Acta Paediatr 2016; 105:890-4. [PMID: 27059606 DOI: 10.1111/apa.13422] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/10/2016] [Accepted: 04/04/2016] [Indexed: 11/30/2022]
Abstract
UNLABELLED 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.
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Affiliation(s)
- Gregory W. Albert
- Division of Neurosurgery; Arkansas Children's Hospital; Little Rock AR USA
- Department of Neurosurgery; University of Arkansas for Medical Sciences; Little Rock AR USA
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18
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Spinal dysraphisms in the parturient: implications for perioperative anaesthetic care and labour analgesia. Int J Obstet Anesth 2015; 24:252-63. [DOI: 10.1016/j.ijoa.2015.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/14/2015] [Indexed: 11/23/2022]
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19
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Sewell MJ, Chiu YE, Drolet BA. Neural tube dysraphism: review of cutaneous markers and imaging. Pediatr Dermatol 2015; 32:161-70. [PMID: 25557454 DOI: 10.1111/pde.12485] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neural tube dysraphisms are congenital anomalies resulting from impaired formation of structures along the craniospinal axis during central nervous system development. When these malformations are large or lack a skin covering, they are easily recognized, whereas smaller or skin-covered malformations may not be readily apparent. Due to the intimate embryologic origin of the skin and nervous system, these occult malformations are often heralded by associated cutaneous abnormalities. In this article, the common clinical presentations and cutaneous markers of craniospinal dysraphism are reviewed, along with the recommended imaging modalities.
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Affiliation(s)
- Matthew J Sewell
- Department of Dermatology, Virginia Commonwealth University, Richmond, Virginia
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20
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The simple sacral dimple: diagnostic yield of ultrasound in neonates. Pediatr Radiol 2015; 45:211-6. [PMID: 24996813 DOI: 10.1007/s00247-014-3110-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/02/2014] [Accepted: 06/22/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although spinal cord tethering is known to be associated with certain clinical syndromes and cutaneous stigmata, its incidence in healthy infants with simple sacral dimples has not been thoroughly evaluated. OBJECTIVE Our objective was to determine the frequency of tethered cord in otherwise healthy patients with simple sacral dimples. MATERIALS AND METHODS We reviewed the lumbar spine US reports of all healthy neonates referred for a simple sacral dimple during a 12-year period at two children's hospitals. A sonogram was considered abnormal for a conus medullaris terminating below the L2-L3 disc space, decreased conus or nerve root motion, an abnormal filum terminale, or for the presence of an intraspinal mass, osseous dysraphism, or a sinus leading to the thecal sac. The medical records of patients with abnormal screening sonograms were reviewed to determine the final clinical outcome. RESULTS During the study period 3,991 infants underwent screening sonography. Of these, 107 were excluded because of the presence of other medical conditions. Of the remaining 3,884 healthy infants, 133 (3.4%) had an abnormal sonogram. Five (0.13%) of these infants were lost to follow-up; 52 subsequently had normal follow-up imaging; 49 had a low conus without other signs of tethering; 18 had a fatty filum; 2 had decreased conus motion; 2 had both a low conus and a fatty filum. None of these infants underwent surgery. Only the remaining 5/3,884 (0.13%) infants underwent surgical intervention (95% CI: 0-0.27%), and 4/5 were found to have a tethered cord intraoperatively. CONCLUSION The risk of significant spinal malformations in asymptomatic, healthy infants with an isolated simple sacral dimple is exceedingly low.
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21
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Kim YS, Jin DH, Shin JH, Lee EH, Choi BM, Hong YS, Je BG. Intraspinal and Urogenital Abnormalities in Infants with Sacral Cutaneous Lesions. NEONATAL MEDICINE 2015. [DOI: 10.5385/nm.2015.22.1.40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Yu Seon Kim
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Da Hee Jin
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jeong Hee Shin
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Eun Hee Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Young Sook Hong
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Bo Gyeong Je
- Department of Radiology, Korea University College of Medicine, Seoul, Korea
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22
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Harada A, Nishiyama K, Yoshimura J, Sano M, Fujii Y. Intraspinal lesions associated with sacrococcygeal dimples. J Neurosurg Pediatr 2014; 14:81-6. [PMID: 24835047 DOI: 10.3171/2014.4.peds13431] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED OBJECT.: Sacrococcygeal dimples in the gluteal fold, also known as coccygeal pits, are observed in 2%-4% of newborns. Sacrococcygeal dimples are not generally considered to be associated with a significant risk of intraspinal anomalies and therefore are not thought to require further radiographic evaluation. Accordingly, the precise incidence and nature of intraspinal lesions that may be associated with sacrococcygeal dimples is unclear. This study was conducted to determine the incidence of intraspinal lesions in patients with intergluteal dimples. METHODS In this study, the authors used MRI to evaluate 103 children who were seen at the Niigata University Medical and Dental Hospital between 2006 and 2011 because of skin abnormalities in the lumbosacral region. Of these children, 14 were excluded as having a subcutaneous fatty mass, and 5 were excluded because the dimples were above the gluteal fold or did not end at the coccyx. The remaining 84 patients were classified according to whether the bottom of the dimple was visible (shallow) or not (deep). The authors also retrospectively examined other skin abnormalities and coexisting anomalies. RESULTS The mean age at the time of MRI evaluation was 11.7 months. Magnetic resonance imaging led to the identification of fibrolipoma of the terminal filum (FTF) in 14 cases (16.7%); 6 of these patients also had a low conus. Classified by depth, there were 58 cases with shallow and 26 with deep dimples. Fibrolipoma of the terminal filum was found in significantly more patients with deep dimples (9 [34.6%]) than in those with shallow dimples (5 [8.6%]). The frequency of other congenital anomalies was significantly higher in patients with FTF-associated dimples (6 [42.9%] of 14) than in those with dimples that were not associated with FTF (9 [12.9%] of 70). CONCLUSIONS Fibrolipoma of the terminal filum was identified by MRI in 16.7% of patients with sacrococcygeal dimples. The risk of FTF increased when the dimples were deeply excavated or were accompanied by congenital anomalies. Magnetic resonance imaging should be performed to identify intraspinal lesions when there are high risk factors for intraspinal abnormalities, or when an ultrasound screening suggests intraspinal abnormalities.
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Affiliation(s)
- Atsuko Harada
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Japan
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23
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Affiliation(s)
- Ajay Kumar
- Department of Neonatology; Lady Hardinge Medical College; New Delhi 110001 India
| | - Rajesh K. Kanojia
- Department of Orthopedics; Lady Hardinge Medical College; New Delhi 110001 India
| | - Arvind Saili
- Department of Neonatology; Lady Hardinge Medical College; New Delhi 110001 India
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24
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Hong M, Lee YK, Ko SY, Shin SM, Han BH, Kim KA. Sacral Cutaneous Clues to Underlying Spinal Abnormalities. NEONATAL MEDICINE 2014. [DOI: 10.5385/nm.2014.21.1.46] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Mee Hong
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center Kwandong University College of Medicine, Seoul, Korea
| | - Yeon Kyung Lee
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center Kwandong University College of Medicine, Seoul, Korea
| | - Sun Young Ko
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center Kwandong University College of Medicine, Seoul, Korea
| | - Son Moon Shin
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center Kwandong University College of Medicine, Seoul, Korea
| | - Byoung Hee Han
- Department of Diagnostic Radiology, Cheil General Hospital & Women's Health Care Center Kwandong University College of Medicine, Seoul, Korea
| | - Kyung A Kim
- Department of Pediatrics, National Police Hospital, Seoul, Korea
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25
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McGovern M, Mulligan S, Carney O, Wall D, Moylett E. Ultrasound investigation of sacral dimples and other stigmata of spinal dysraphism. Arch Dis Child 2013; 98:784-6. [PMID: 23908189 DOI: 10.1136/archdischild-2012-303564] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess whether there was any relationship between the number of clinical markers for spinal dysraphism and its presence on ultrasound and whether there was any relationship between the presence of an isolated sacral dimple and the presence of spinal dysraphism. Outcomes and further imaging were also examined. METHODS All patients who underwent spinal ultrasound (SUS) in University Hospital Galway (UHG) over a 5-year period (2006-2011) were identified. Patients were excluded based on age (>14 years old excluded) and indication for imaging (only patients being investigated for suspected spinal dysraphism were included). Indications for imaging, ultrasound results and information on further imaging were accessed from the computerised radiology software in UHG. Statistical analysis was performed using SPSS-18. RESULTS Data were analysed for 216 patients. A single clinical indication was recorded for 174 ultrasound requests, ≥2 indications for 42 requests. Nineteen of 216 (8.8%) ultrasound images were abnormal, 7 having spinal dysraphism. Multiple clinical indications were 6 times more likely to have dysraphism than those imaged on the basis of a single marker (OR 6.0, 95% CI 1.289 to 27.922, p=0.022), and there was no significant correlation between the presence of a sacral dimple and the presence of dysraphism (95% CI 0.71 to 6.622, p=0.722). CONCLUSIONS SUS performed on the basis of multiple clinical indications is six times more likely to detect spinal dysraphism than imaging performed for isolated abnormalities or risk factors. Sacral dimple is a poor marker for occult spinal pathology.
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Affiliation(s)
- Matthew McGovern
- Academic Department of Paediatrics, National University of Ireland Galway, , Galway, Ireland
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26
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Mostafa M, Nasef N, Barakat T, El-Hawary AK, Abdel-Hady H. Acute flaccid paralysis in a patient with sacral dimple. World J Clin Pediatr 2013; 2:26-30. [PMID: 25254171 PMCID: PMC4145641 DOI: 10.5409/wjcp.v2.i3.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/08/2013] [Indexed: 02/06/2023] Open
Abstract
Sacral dimples are the most common cutaneous anomaly detected during neonatal spinal examination. Congenital dermal sinus tract, a rare type of spinal dysraphism, occurs along the midline neuraxis from occiput down to the sacral region. It is often diagnosed in the presence of a sacral dimple together with skin signs, local infection, meningitis, abscess, or abnormal neurological examination. We report a case of acute flaccid paralysis with sensory level in a 4 mo old female infant with sacral dimple, diagnosed by magnetic resonance imaging to be a paraspinal subdural abscess. Surgical exploration revealed a congenital dermal sinus tract extending from the subdural abscess down to the sacral dimple and open to the exterior with a minute opening.
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Occult spinal dysraphism in the presence of rare cutaneous stigma in a neonate: importance of ultrasound and magnetic resonance imaging. Case Rep Med 2013; 2013:468376. [PMID: 23762072 PMCID: PMC3677004 DOI: 10.1155/2013/468376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 05/13/2013] [Indexed: 01/15/2023] Open
Abstract
Occult spinal dysraphism is defined as a group of dystrophic conditions below an intact cover of dermis and epidermis. Ultrasonography using linear transducers is a fast, inexpensive, and effective method that makes it possible to view the content of the vertebral canal and bone structures. Magnetic resonance imaging (MRI) is reserved for elucidating the type of dysraphism and for planning corrective surgery. We present a case of a five-day-old female neonate who presented cutaneous stigmas (in the lumbar region, hands, and feet), in whom ultrasonography demonstrated dysraphism in the lumbar region. MRI confirmed the type of dysraphism and enabled surgical planning.
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KOO BN, HONG JY, SONG HT, KIM JM, KIL HK. Ultrasonography reveals a high prevalence of lower spinal dysraphism in children with urogenital anomalies. Acta Anaesthesiol Scand 2012; 56:624-8. [PMID: 22338610 DOI: 10.1111/j.1399-6576.2011.02612.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND Lower spinal dysraphism is frequently reported in anorectal anomaly combined with urogenital anomalies. The prevalence of the spinal dysraphism has not been comprehensively studied in children with simple urogenital anomalies. We evaluated the prevalence of the spinal dysraphism using ultrasound data of the lumbosacral area in children with urogenital anomalies. METHODS Lumbosacral ultrasound images of 259 children who underwent urological surgery with simple urogenital anomalies were reviewed by an ultrasound-specialized radiologist. The primary outcome measures were the conus medullaris (CM) level and the thickness of the filum terminale. The spinal ultrasonographic findings that were assessed in children showed abnormal spinal findings compared with the other children having normal findings. Two years later, the follow-up telephone interviews were made with the parents of the children with abnormal findings. RESULTS Eighteen children were differentiated as the abnormal finding group. They were suspected of spinal cord tethering. The level of CM was lower, and the filum terminale was thicker compared to the normal group [L2(lower (L)) vs. L1(L), 2.2 mm vs. 0.8 mm]. Of eighteen children, four were confirmed as tethered spinal cord with lipoma on magnetic resonance imaging by the time of surgery, and two were strongly suspected of occult spinal dysraphism (OSD) based on ultrasound findings and follow-up interviews. CONCLUSIONS The prevalence of OSD in children under 24 months of age with simple urogenital anomaly was higher than what was reported for the general population. Ultrasound examination of spinal structures before caudal block in children with urogenital anomaly should be considered.
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Affiliation(s)
- B.-N. KOO
- Department of Anaesthesiology & Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul; Korea
| | - J.-Y. HONG
- Department of Anaesthesiology and Pain Medicine; University of Ulsan College of Medicine, Asan Medical Center; Seoul; Korea
| | - H.-T. SONG
- Department of Radiology; Yonsei University College of Medicine; Seoul; Korea
| | - J. M. KIM
- Department of Anaesthesiology & Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul; Korea
| | - H. K. KIL
- Department of Anaesthesiology & Pain Medicine; Anaesthesia and Pain Research Institute; Yonsei University College of Medicine; Seoul; Korea
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Chern JJ, Kirkman JL, Shannon CN, Tubbs RS, Stone JD, Royal SA, Oakes WJ, Rozzelle CJ, Wellons JC. Use of lumbar ultrasonography to detect occult spinal dysraphism. J Neurosurg Pediatr 2012; 9:274-9. [PMID: 22380955 DOI: 10.3171/2011.12.peds11351] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECT Various cutaneous stigmata and congenital anomalies are accepted as sufficient reasons to perform lumbar ultrasonography as a screening tool to rule out occult spinal dysraphism (OSD). The purpose of this study was to correlate presenting cutaneous findings with lumbar ultrasonography results based on a large number of lumbar ultrasonography tests obtained by regional primary care providers. METHODS Over the course of 5 years, 1273 infants underwent lumbar ultrasonography screening at a major pediatric tertiary referral center. Of these infants, 1116 had adequate documentation for retrospective chart review. Referral sources included urban academic, urban private practice, and surrounding rural private practitioners. Presence of cutaneous stigmata and/or congenital anomalies and lumbar ultrasonography results were reviewed for all patients. When present, surgical findings were reviewed. RESULTS A total of 943 infants were referred for presumed cutaneous stigmata, the most common of which was a sacral dimple (638 patients [68%]) followed by hairy patch (96 patients [10%]). Other reported cutaneous findings included hemangioma, deviated gluteal fold, skin tag, and skin discoloration. In comparison, 173 patients presented with congenital anomalies, such as imperforate anus (56 patients [32%]) and tracheoesophageal fistula/esophageal atresia (37 patients [21%]), most of which were detected prenatally by fetal ultrasonography. A total of 17 infants underwent surgical exploration. Occult spinal dysraphism was diagnosed in 7 infants in the cutaneous stigmata group and in 10 infants in the group with congenital abnormalities. None of the cutaneous stigmata as recorded were found to be indicative of the presence of OSD. CONCLUSIONS Cutaneous markers as currently defined by general practitioners are not useful markers for predicting OSD. The vast majority of findings on lumbar ultrasonography studies performed under these circumstances will be negative.
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Affiliation(s)
- Joshua J Chern
- Department of Pediatric Neurosurgery, Children's Hospital, Universityof Alabama, Birmingham, AL, USA.
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AIUM practice guideline for the performance of an ultrasound examination of the neonatal spine. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:155-164. [PMID: 22215784 DOI: 10.7863/jum.2012.31.1.155] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Rios LTM, Oliveira RVBD, Martins MDG, Leitão OMR, Simões VMF, Nascimento JMSD. Lipoma espinhal associado a seio dérmico congênito: relato de caso. Radiol Bras 2011. [DOI: 10.1590/s0100-39842011000400014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Os lipomas espinhais são raros, respondendo por 1% de todos os tumores espinhais, estando associados ao disrafismo espinhal oculto em mais de 99% dos casos. Estão divididos em três tipos principais: lipomielomeningocele, lipoma intradural e fibrolipoma do filo terminal. Este relato descreve um caso de lipoma lombossacral congênito associado a estigma cutâneo do tipo seio dérmico lombar congênito.
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International survey on the management of skin stigmata and suspected tethered cord. Childs Nerv Syst 2010; 26:1719-25. [PMID: 20563728 DOI: 10.1007/s00381-010-1184-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 05/11/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES We designed a survey to investigate current international management trends of neonates with lumbar midline skin stigmata suspicious of tethered cord, among pediatric neurosurgeons, focusing on the lower risk stigmata, simple dimples, deviated gluteal folds, and discolorations. Our findings will enable physicians to assess their current diagnosis routine and aid in clarifying management controversies. STUDY DESIGN A questionnaire on the proposed diagnostic evaluation of seven case reports, each accompanied by relevant imaging, was distributed by e-mail to members of the International Society for Pediatric Neurosurgery, the European Society for Pediatric Neurosurgery, and via the PEDS server list between March and August 2008. RESULTS Sixty-two questionnaires, completed by experienced professionals with a rather uniform distribution of experience levels, were analyzed. Forty-eight percent do not recommend any imaging of simple dimples, 30% recommend US screening and 22% recommend MR. Seventy-nine percent recommend imaging of deviated gluteal fold with 30% recommending MR. Ninety-two percent recommend imaging infants with hemangiomas with 74% recommending MR. MR for sinus tracts is recommended by 90% if sacral and by 98% if lumber. Eighty-four percent recommend MR for filar cyst. CONCLUSIONS Our survey demonstrates that management of low-risk skin stigmata, simple dimple, deviated gluteal fold, and discolorations lacks consensus. In addition, a significant sector of the professional community proposes a work-up of simple dimples, sacral tracts, and filar cysts that contradicts established recommendations. A simple classification system is needed to attain a better approach, enabling correct diagnosis of tethered cord without exposing neonates to unnecessary examinations.
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Kim SM, Chang HK, Lee MJ, Shim KW, Oh JT, Kim DS, Kim MJ, Han SJ. Spinal dysraphism with anorectal malformation: lumbosacral magnetic resonance imaging evaluation of 120 patients. J Pediatr Surg 2010; 45:769-76. [PMID: 20385285 DOI: 10.1016/j.jpedsurg.2009.10.094] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Revised: 10/05/2009] [Accepted: 10/30/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE We evaluated the prevalence of spinal dysraphism (SD) in patients with anorectal malformation (ARM) by magnetic resonance imaging (MRI). METHODS From January 2002 to March 2009, 120 patients with ARM who underwent anorectal reconstruction were evaluated for SD with sacral plain film, spinal ultrasonography (US), and lumbosacral MRI. We adopted Krickenbeck international classification of ARM. RESULTS Spinal dysraphism was present in 41 (34.2%) of 120 patients with ARM, 3 (13.0%) of 23 patients with perineal fistula, 7 (29.2%) of 24 patients with vestibular fistula, 4 (36.4%) of 11 patients with rectovesical fistula, 18 (40.9%) of 44 patients with rectourethral fistula, and 9 (60.0%) of 15 patients with cloacal anomaly (P = .04). Among 41 patients having SD detected by MR, 26 patients (26/41; 63.4%) underwent detethering surgery for tethered spinal cord. The mean sacral ratio (SR) in patients who underwent detethering surgery (0.54 +/- 0.19) was significantly lower than in patients who did not undergo detethering surgery (0.69 +/- 0.13; P < .001). The optimal cutoff for the SR value predicting SD requiring detethering surgery was 0.605, with sensitivity of 65.4% and specificity of 77.7%. CONCLUSIONS Spinal dysraphism is common in patients with ARM, and its prevalence is higher in patients with complex ARM. Spinal anomalies can occur even with benign types of ARM and, therefore, that all patients should be screened. Magnetic resonance imaging is useful in detecting occult SD that may be missed by conventional radiologic evaluation, physical examination, and spinal US. We further recommend a lumbosacral MRI examination in those whose SR is lower than 0.6.
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Affiliation(s)
- Seong Min Kim
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, South Korea
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Sardana K, Gupta R, Garg VK, Mishra D, Mishra P, Grover C, Mendiratta V. A prospective study of cutaneous manifestations of spinal dysraphism from India. Pediatr Dermatol 2009; 26:688-95. [PMID: 20199442 DOI: 10.1111/j.1525-1470.2009.01014.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Recognition of cutaneous markers of spinal dysraphism is important to prevent the morbidity associated with underlying spinal anomalies. To investigate the frequency and type of cutaneous stigmata in different forms of spinal dysraphism and to assess the role of ultrasonography and/or magnetic resonance imaging in diagnosing spinal dysraphism at two pediatric dermatology tertiary care centers. Over a 4-year period, all pediatric patients presenting to the dermatology clinic with dorsal midline cutaneous stigmata were evaluated clinically and with imaging studies (radiography, ultrasonographic examination and magnetic resonance imaging/Doppler). Surgical interventions were planned in conjunction with neurosurgery and orthopedic specialists. On examination, 245 (4.2%) had 285 cutaneous stigmata. Of the 180 patients evaluated with radiography, ultrasonographic examination and magnetic resonance imaging, 50 patients (28%) had spinal dysraphism (with 64 cutaneous stigmata). The most common stigmata associated with occult spinal dysraphism were lipoma (10) and dimples (12) and in open spinal dysraphism lipomeningomyelocoele (10) and meningomyelocoele (10). Statistically, lipomeningomyelocoele/myelomeningocoele, atypical dimples and port-wine stains were most associated with spinal dysraphism (p < 0.001). In 80 children less than 6 months of age, radiography with ultrasonographic examination revealed an SD in 16, while magnetic resonance imaging was diagnostic in four cases. Ultrasonographic examination performed fairly well in children less than 6 months and in cases of flat cutaneous stigmata it missed only 5% of cases, but in cases with bulky overlying masses (lipoma, hemangioma) it missed 15% of cases.
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Affiliation(s)
- Kabir Sardana
- Dermatology, Maulana Azad Medical College and Lok Nayak Hospital, Delhi, India.
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Patterson S. Sonographic Assessment of the Neonatal Spine and the Potential for New Technologies to Aid in Diagnoses. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2009. [DOI: 10.1177/8756479308327063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many spinal disorders, whether congenital or acquired, are likely to have an improved outcome if they are promptly identified. A rapid diagnosis may eliminate progressive sequela and provide insight to possible treatment plans. Although there are various medical imaging modalities for evaluating the neonatal spine, diagnostic medical sonography provides a safe (no exposure to ionizing radiation), quick, and inexpensive approach. Spinal diagnostic medical sonography can be performed in neonates as long as the vertebral column is not completely ossified. Diagnostic medical sonography is a valuable technique that, in addition to 2D imaging, provides 3D, extended field of view (EFOV), and M-mode imaging. Diagnostic medical sonography can identify normal spinal anatomy and variants, congenital malformations, and acquired diseases subsequent to birth-related trauma and lumbar punctures. This article discusses the normal embryology of the spine. Indications for neonatal spinal diagnostic medical sonography are reviewed along with a description of sonographic examination techniques. A review of spinal pathology and their embryological origin will be outlined as well as normal variants seen with sonography. A detailed literature review is provided evaluating case studies and their findings.
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Affiliation(s)
- Shanna Patterson
- University of Wisconsin Hospital & Clinics, School of Diagnostic Medical Sonography, Madison, WI,
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D'Addario V, Rossi AC, Pinto V, Pintucci A, Di Cagno L. Comparison of six sonographic signs in the prenatal diagnosis of spina bifida. J Perinat Med 2008; 36:330-4. [PMID: 18598123 DOI: 10.1515/jpm.2008.052] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To compare the diagnostic accuracy of sonographic signs that may be looked for in fetuses with spina bifida. METHODS Forty-nine fetuses affected by spina bifida were enrolled, at a gestational age of 18-28 weeks. The following sonographic signs were looked for: "lemon" sign, small cerebellum, effaced cisterna magna, small posterior fossa, ventriculomegaly and direct visualization of a spinal defect. RESULTS The "lemon" sign was present in 53%, a small cerebellum in 96%, an effaced cisterna magna in 93%, a small posterior fossa in 96%. Ventriculomegaly was present in 40/49 (81%) cases and was severe in 20 fetuses and borderline in the remaining 20. The spinal defect was missed in one fetus presenting the cerebellar and posterior fossa signs. In two fetuses, the myelomeningocele was present without cranial signs of Chiari II malformation and in both cases the defect was covered by intact skin. CONCLUSIONS Our results confirm the usefulness of evaluation of the posterior fossa in the diagnosis of spina bifida, particularly in cases of small spinal defects that may be missed at ultrasound. Conversely, myelomeningocele covered by intact skin was not associated with the cranial signs of Chiari II malformation.
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Affiliation(s)
- Vincenzo D'Addario
- Department of Obstetrics, Gynecology and Neonatology, University of Bari, Bari, Italy.
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Abstract
Spinal dysraphism, an incomplete closure of the neural tube, can be open, exposing the neural elements to the environment, or can be closed, covered with skin. Abnormal development of the spine occurs early in life and also interferes with usual development of the skin. This often creates cutaneous markers or stigmata over the area. Cutaneous markers may include a subcutaneous mass, abnormal hair growth, skin dimple, tag or sinus, or unusual pigmentation. Recognizing these markers is important because, although many closed spinal dysraphisms are asymptomatic at birth, neurological sequelae can occur. The sequelae are insidious and often permanent. This article, Part 3 in a series of articles devoted to spinal assessment, reviews closed spinal dysraphisms. The article emphasizes identification of various cutaneous markers associated with closed spinal dysraphisms. Early detection and follow-up may prevent neurologic sequelae for the infant later in life.
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Affiliation(s)
- M Colleen Brand
- Neonotal Nurse Practitioner Service, Texas Children's Hospital, 6621 Fannin, MC:AB480.04, Houston, TX 77030, USA.
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Abstract
The complexity of the congenital anomalies of the spine can make the neuroradiologic diagnosis challenging. Knowledge of spinal embryology greatly helps in the understanding and classification of these anomalies. We use the classification devised by Tortori-Donati and Rossi and find it helpful from clinical and imaging standpoints. We believe that most patients who have known or suspected congenital spinal anomalies benefit from MR imaging.
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Affiliation(s)
- John D Grimme
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7510, USA
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Bademci G, Saygun M, Batay F, Cakmak A, Basar H, Anbarci H, Unal B. Prevalence of primary tethered cord syndrome associated with occult spinal dysraphism in primary school children in Turkey. Pediatr Neurosurg 2006; 42:4-13. [PMID: 16357495 DOI: 10.1159/000089503] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Accepted: 07/07/2005] [Indexed: 11/19/2022]
Abstract
The prevalence and associated factors of primary tethered cord syndrome (PTCS) in primary school children were investigated. A cross-sectional study was performed in four demographically different primary schools in Turkey. Demographic, familial and physical data were collected from 5,499 children based on enuresis as a predominant symptom and dermatologic and orthopedic signs as clues of occult spinal dysraphism. Statistical analysis and input of the data were carried out with the SPSS package program 10.00, and logistic regression analysis was used to identify discriminating factors between enuretic children with or without neurologic signs. Of 5,499 analyzed children, 422 (7.7%) had enuresis nocturna, and 19.9% of 422 children had also daytime incontinence. Sixteen of these 422 enuretic children (3.8%) had several dermatologic signs. Five of them had spina bifida on plain radiographies, and 4 of them had cord tethering on lumbar MRI. Fifteen of 422 enuretic children (3.7%) had gait disturbances and orthopedic anomalies without cutaneous manifestations. Six of 15 children had spina bifida on plain graphies and 2 of them had tethered cord syndrome on MRI. The general prevalence of PTCS was found to be 0.1% of 5,499 analyzed children and 1.4% of enuretic children. A good outcome after untethering was found in 83.0% in this series. Practitioners should be aware of these clues of occult spinal dysraphism and resort to further radiologic and neurosurgical assessment. Early surgical intervention may halt the progression of the neurologic deficits and stabilize or reverse symptoms.
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Affiliation(s)
- Gulsah Bademci
- Department of Neurosurgery, Faculty of Medicine, University of Kirikkale, Kirikkale, Turkey.
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Abstract
Ultrasound examination is often the most effective and sometimes the only practical means of examining children with soft tissue, tendon and joint diseases. This review will cover the important application of diagnostic ultrasound in children musculoskeletal disorders. We will consider topics where ultrasound is the only sensible means of examination such as developmental dysplasia of the hip, where it is the best choice of several possible methods such as painful hip and when it provides an alternative or adjunct to other imaging such as the examination of soft tissue masses.
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Affiliation(s)
- G Allen
- Royal Orthopaedic Hospital, Bristol Road South, Northfield, B312AP, Birmingham, UK
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Szyszko TA, Watson M. The value of ultrasonographic examination of the lumbar spine in infants with specific reference to cutaneous markers of occult spinal dysraphism. Clin Radiol 2005; 60:935. [PMID: 16039931 DOI: 10.1016/j.crad.2005.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Accepted: 02/24/2005] [Indexed: 11/23/2022]
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