Seven distinct coexistent cranial and spinal anomalies

Do we need to scan the whole neuraxis for coexistent abnormalities in children with surgically treated occult spinal dysraphism?

BACKGROUND

Spina bifida occulta (SBO) is generally known as a benign isolated entity; however, there are ambiguous approaches for neuroaxial screening in cases of symptomatic SBO among institutions. This study aims to demonstrate the infrequency of cranial anomalies associated with symptomatic SBO and inquire the necessity of cranial radiological surveillance in those patients.

METHODS

Between 2012 and 2016 pediatric patients who were surgically treated in our clinic due to symptomatic SBO were retrospectively evaluated. All radiological findings in craniospinal evaluation were documented.

RESULTS

There were 76 patients with mean age of 5.3 years (range 2 months to 17 years), and female predominance (53 female and 23 male patients). Of those, 64 patients had whole neuroaxis investigation including cranial imaging. Among 64 patients with cranial screening, only two patients had occipital encephalocele and posterior fossa arachnoid cyst. There was neither hydrocephalus nor Chiari malformation in our case series.

CONCLUSIONS

We detected high number of additional spinal abnormalities accompanying to symptomatic SBOs, whereas cranial findings rarely coexisted with them. Therefore, we strongly suggest the radiological screening of whole spinal axis in occult spinal dysraphism with significant spinal findings. On the other hand, cranial imaging as a part of neuraxis screening in cases of symptomatic SBOs is not required in all cases; however, it can be done in selected patients where clinically indicated.

Complex forms of spinal dysraphism

INTRODUCTION

Spinal dysraphisms are a heterogeneous group of congenital malformations involving the bony component of vertebrae or spinal cord or both. Simple forms include the contiguous, solitary malformations such as myelomeningocele and diastematomyelia, and can be either aperta or occulta type.

MATERIAL

Complex forms include various types of spinal malformations occurring in combination, one type of malformations occurring at multiple levels in noncontiguous manner or spinal dysraphisms with other organ anomalies. Anomalous development in gastrulation, primary neurulation, and secondary neurulation stage in variable proportions give rise to these types of complex malformations. These cases can be diagnosed postnatally in early infancy by the strong clinical suspicion, supplemented by whole spinal axis and cranial magnetic resonance imaging (MRI) screening, to detect any occult spinal dysraphisms like split cord malformations, neurenteric cyst, lipoma, or cranial anomalies like Chiari malformations and hydrocephalus. Computed tomography and MRI are the gold standard to detect bony anomalies and cord malformations, respectively. Complex spinal dysraphisms, to our mind, should always be tried to be corrected in single operative stage, however, in case of ruptured defects, correction through multiple operations can be considered.

DISCUSSION

Overall, prognosis of complex forms of spinal dysraphism is poor in comparison to their simple forms and depends on preoperative neurological status and the nature of complex dyraphism. We discuss the classification, embryogenesis, investigation, and treatment protocol with review of literature of such complex anomalies.

Concurrent Chiari decompression and spinal cord untethering in children: feasibility in a small case series

BACKGROUND AND PURPOSE

We describe the rationale and safety of concurrent decompression of Chiari type 1 malformation (CM1) and untethering of the spinal cord. Spinal cord traction is considered one of the pathogenic mechanisms involved in the development of CM, and 14% of patients with CM1 have tethered cord syndrome (Milhorat et al., Surg Neurol 7:20-35, 2009; Roth, Neuroradiology 21:133-138, 1981; Royo-Salvador, Rev Neurol 24:937-959, 1996; Royo-Salvador et al., Acta Neurochir 147:515-523, 2005). Therefore, intraspinal anomalies that require intervention are commonly treated before surgical decompression of Chiari malformation (Cheng et al., Neurologist 8:357-362, 2002; Menezes, Pediatr Neurosurg 23:260-269, 1995; Milhorat et al., Surg Neurol 7:20-35, 2009; Royo-Salvador et al., Acta Neurochir 147:515-523, 2005; Schijman and Steinbok, Childs Nerv Syst 20:341-348, 2004; Yamada et al., Neurol Res 26:719-721, 2004). However, in the interval between the spinal cord untethering and the decompression surgery, patients may continue to suffer from the untreated symptoms of CM. In a series of four patients with concurrent severe and progressive symptoms referable to both conditions, we performed both surgeries simultaneously.

METHODS

Charts of four patients who underwent concurrent Chiari decompression and spinal cord untethering were reviewed.

RESULTS

All patients tolerated the procedures well without complication. They reported significant or complete early postsurgical resolution of headaches and ambulating difficulties. On average, patients started to walk on postoperative day 3 (3 ± 1 days) and were discharged on hospital day 6 (6 ± 1 days). No patient experienced a persistent subcutaneous or transcutaneous cerebrospinal fluid leak. Subsequent postoperative courses were uneventful.

CONCLUSION

Concurrent Chiari decompression and untethering of the spinal cord is a feasible option and in some patients may be preferred in lieu of staged procedures.

Myelomeningocele associated with split cord malformation type I -three case reports-

Three neonates presented with split cord malformation (SCM) associated with myelomeningocele (MMC), complicated with various coexisting anomalies. All patients were female and classified as SCM type I. All patients had a syrinx located rostral to the SCM. One patient had hydrocephalus and Chiari malformation causing serious respiratory problems. Two patients had partial hypertrichosis located close to the MMC, suggesting association with SCM. One patient had sacral hypoplasty and right kidney agenesis, suggesting that some embryologic errors may affect not only neural but also mesodermal development. All patients underwent surgical treatment for SCM after detailed evaluation and management of concomitant anomalies, and developed no new neurological deficits. Delayed surgery is an alternative treatment strategy for SCM in patients with both SCM and MMC with similar complications.