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Nawashiro T, Kurimoto M, Nagakura M, Kato M, Aoki K, Saito R. Comparison of the inter-laminar approach and laminotomy open approach for filum terminale lipoma: A retrospective analysis. Childs Nerv Syst 2024:10.1007/s00381-024-06507-4. [PMID: 38958731 DOI: 10.1007/s00381-024-06507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Filum terminale lipoma (FTL) causes spinal-cord tethering and is associated with tethered-cord syndrome, which is treated by dissection of the entrapment. The conventional treatment for FTL involves dissection of the spinal cord through a laminotomy open approach (LOA). However, in recent years, the interlaminar approach (ILA) has gained popularity as a minimally invasive surgery. This study compares the effectiveness of the minimally invasive ILA with the conventional LOA in treating FTL. METHODS We retrospectively evaluated data on the ILA and LOA for FTL at our center. In total, 103 participants were enrolled, including 55 in the ILA group and 48 in the LOA group. RESULTS The ILA required significantly less surgical time and resulted in less blood loss. The improvement rate of symptoms in symptomatic patients was 84%, and for urinary symptoms and abnormal urodynamic study findings, it was 77%. The postoperative maintenance rate for asymptomatic patients was 100%. Postoperative complications of ILA included delayed wound healing in two patients (3.6%). CONCLUSION Compared with LOA, ILA offers advantages in terms of shorter operative time and less blood loss, with no significant difference in long-term symptom-improvement rates between the groups.
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Affiliation(s)
- Tomoki Nawashiro
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Michihiro Kurimoto
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan.
| | - Masamune Nagakura
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Mihoko Kato
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Kousuke Aoki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Ogura R, Fujiwara H, Natsumeda M, Hiraishi T, Sano M, Oishi M. Preoperative interactive virtual simulation applying three-dimensional multifusion images using a haptic device for lumbosacral lipoma. Childs Nerv Syst 2024; 40:1129-1136. [PMID: 37987859 DOI: 10.1007/s00381-023-06234-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE Untethering surgery for lumbosacral lipoma is a preventive procedure, and avoidance of complications and good long-term outcomes are required. We introduced presurgical interactive virtual simulation (IVS) applying three-dimensional multifusion images using a haptic device aimed at improving operative outcomes. METHODS Fourteen patients with newly diagnosed lumbosacral lipoma were recruited and underwent preoperative IVS. The median age at surgery was 8 months. A three-dimensional image analysis system was used to extract and fuse structures necessary for surgery, such as the lipoma, spinal cord and skin, from CT and MRI, and create three-dimensional multifusion images. The created images were individually converted to standard triangulated language format and loaded onto a workstation (Geomagic freeform™) that could be freely transformed, and the laminectomy range and lipoma extraction procedure were examined. Presurgical IVS was performed, and the actual surgery was performed. RESULTS The disease types were dorsal, caudal, lipomyelomeningocele, transitional, and filum in 5, 5, 2, 1, and 1 patients, respectively. The surgical procedure and extent of the laminectomy were as planned for all patients. Resection of the lipomas tended to be less than expected preoperatively because of positive reactions on intraoperative monitoring. No postoperative complications were observed. The median postoperative follow-up period was 29 months, and there were no reoperations during the observation period. CONCLUSIONS Although there are various types of lumbosacral lipoma, surgery can be safely performed by performing presurgical IVS. The short-term course is good; however, long-term follow-up is necessary for the appearance of neurological symptoms associated with growth and re-tethering.
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Affiliation(s)
- Ryosuke Ogura
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi, Chuo-ku, Niigata, 951-8585, Japan.
| | - Hidemoto Fujiwara
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi, Chuo-ku, Niigata, 951-8585, Japan
| | - Manabu Natsumeda
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi, Chuo-ku, Niigata, 951-8585, Japan
| | - Tetsuya Hiraishi
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi, Chuo-ku, Niigata, 951-8585, Japan
| | - Masakazu Sano
- Department of Neurosurgery, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Makoto Oishi
- Department of Neurosurgery, Brain Research Institute, Niigata University, 1-757 Asahimachi, Chuo-ku, Niigata, 951-8585, Japan
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Casado-Ruiz J, Ros B, Iglesias S, Ros A, Arráez MA. Spinal cord lipomas: lessons learned in the era of total resection. Childs Nerv Syst 2024; 40:1121-1128. [PMID: 38103091 DOI: 10.1007/s00381-023-06251-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Recent years have seen a paradigm shift towards total/near-total resection in spinal cord lipoma surgery. As this procedure is technically challenging, surgical candidates need to be selected appropriately through accurate image assessment and classification. The purpose of this paper is to describe a surgical series of paediatric spinal cord lipomas, their diagnosis, results and complications. METHODS We undertook a retrospective review of paediatric patients with spinal cord lipomas who underwent surgery between 2008 and 2022. The variables studied were age, gender, preoperative symptoms according to the Necker Functional Score (NFS), type of lipoma according to Morota's classification, functional and radiological surgical outcomes using the cord-sac ratio (CSR), need for re-operation, complications and follow-up. RESULTS A total of 25 patients (average age 36 months) underwent surgery. According to Morota's classification, MRI showed 13 type 1 lipomas, two type 2, two type 3 and eight type 4. The preoperative NFS was 16.06, with urological abnormalities being the most frequent manifestation. Total/near-total resection was attempted since 2015. Five patients with type 1 lipoma required re-operation due to clinical deterioration with suspected retethering, all of them with a CSR > 0.3. The series average CSR was 0.417. CONCLUSIONS This paper highlights the importance of proper classification for a correct surgical approach to obtain favourable results and minimise possible complications. Based on our experience, given our results regarding the percentage of fistulae and retethering rates, we limited radical resection to symptomatic type 1 lipomas. Our future aim is to obtain better CSR rates and to decrease the retethering percentage.
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Affiliation(s)
- Julia Casado-Ruiz
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain.
| | - Bienvenido Ros
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
| | - Sara Iglesias
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
| | - Angela Ros
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
| | - M A Arráez
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
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Perera D, Craven CL, Thompson D. Lumbosacral lipoma in childhood, how strong is the evidence base? A systematic review. Childs Nerv Syst 2024; 40:715-728. [PMID: 37924337 DOI: 10.1007/s00381-023-06203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Conus region lumbosacral lipomas (LSLs) are highly heterogeneous in their morphology, clinical presentation, and outcome, with an incompletely understood natural history and often treacherous surgical anatomy. This systematic review aims to critically evaluate and assess the strength of the current LSL evidence base to guide management strategies. METHODS According to a systematic review following PRISMA guidelines, a search was conducted using the key term "lumbosacral lipoma" across MEDLINE (OVID), Embase, Cochrane Library, and PubMed databases from January 1951 to April 2021. All studies containing ten or more paediatric conus lipomas were included. Data heterogeneity and bias were assessed. RESULTS A total of 13 studies were included, containing 913 LSLs (predominantly transitional type-58.5%). Two-thirds (67.5%) of all patients (treated and non-treated) remained clinically stable and 17.6% deteriorated. Neuropathic bladder was present in 8.6% at final follow-up. Of patients managed surgically, near-total resection vs. subtotal resection deterioration-free survival rates were 77.2-98.4% and 10-67% respectively. 4.5% (0.0-27.3%) required re-do untethering surgery. Outcomes varied according to lipoma type. Most publications contained heterogeneous populations and used variable terminology. There was a lack of consistency in reported outcomes. CONCLUSION Amongst published series, there is wide variability in patient factors such as lipoma type, patient age, and methods of (particularly urological) assessment. Currently, there is insufficient evidence base upon which to make clear recommendations for the management of children with LSL. There is an imperative for neurosurgeons, neuroradiologists, and urologists to collaborate to better standardise the terminology, assessment tools, and surgical interventions for this challenging group of conditions.
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Affiliation(s)
- Duranka Perera
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | - Claudia L Craven
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | - Dominic Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK.
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Lim JX, Fong E, Goh C, Ng LP, Low DCY, Seow WT, Low SYY. Complex lumbosacral spinal cord lipomas: A longitudinal study on outcomes from a Singapore children's hospital. J Clin Neurosci 2024; 121:119-128. [PMID: 38394955 DOI: 10.1016/j.jocn.2024.02.017] [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: 09/22/2023] [Revised: 01/28/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Total/near-total resection (TR/NTR) of complex lumbosacral lipomas (CSL) is reported to be associated with better long-term functional outcomes and lower symptomatic re-tethering rates. We report our institutional experience for CSL resection in affected children. METHODS This is a single-institution, retrospective study. Inclusion criteria consist of patients with CSL with dorsal, transitional and chaotic lipomas based on Pang et al's classification. The study population is divided into 2 groups: asymptomatic patients with a normal preoperative workup referred to as 'prophylactic intent' and 'therapeutic intent' for those with pre-existing neuro-urological symptoms. Primary aims are to review factors that affect post-operative clean intermittent catheterization (CIC), functional outcomes based on Necker functional score (NFS), and re-tethering rates. RESULTS 122 patients were included from 2000 to 2021. There were 32 dorsal lipomas (26.2 %), 74 transitional lipomas (60.7 %), and 16 chaotic lipomas (13.1 %). 82 % patients achieved TR/NTR. Favourable NFS at 1-year was 48.2 %. The re-tethering rate was 6.6 %. After multivariable analysis, post-operative CIC was associated with median age at surgery (p = 0.026), lipoma type (p = 0.029), conus height (p = 0.048) and prophylactic intent (p < 0.001). Next, extent of lipoma resection (p = 0.012) and the post-operative CSF leak (p = 0.004) were associated with re-tethering. Favourable NFS was associated with lipoma type (p = 0.047) and prophylactic intent surgery (p < 0.001). CONCLUSIONS Our experience shows that TR/NTR for CSL is a feasible option to prevent functional deterioration and re-tethering. Efforts are needed to work on factors associated with post-operative CIC.
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Affiliation(s)
- Jia Xu Lim
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - Elizabeth Fong
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - Cheryl Goh
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Paediatrics Academic Clinical Program, 100 Bukit Timah Road, Singapore 229899, Singapore.
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Raj S, Chouksey P, Shrivastava A, Mishra R, Tandon A, Prakash M, Agrawal A. Non-dysraphic extramedullary intradural spinal lipoma with neurocutaneous melanocytosis. Br J Neurosurg 2023; 37:1824-1828. [PMID: 34148439 DOI: 10.1080/02688697.2021.1937518] [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: 01/19/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Intradural spinal lipomas are very rare and constitute less than 1% of all spinal tumors. Such tumors are usually associated with spinal dysraphism and occur mostly in the lumbosacral or cervical region. Intradural spinal lipomas tends to be intramedullary or subpial. Meningeal melanocytoma is further rarer cases that comprise less than 0.1% of cases. These usually occur in the fifth or fifth decade and chances of malignant transformation are high. CASE REPORT Here, we report an extremely rare case (first to the best of our knowledge) of a 9 years female child who presented to us with rapid progressing paraparesis. She was operated and found to have an intradural purely extramedullary spinal lipoma without spinal dysraphism. Moreover, she had melanin pigment deposits all over her meninges which is further rare. On presentation, the patient was bedridden but after surgery, the patient improved and could walk without support. CONCLUSIONS To the best of our knowledge, this is the first case of spinal cord lipoma in dorsal location along with melanin pigments in the meninges. We discuss the pathogenesis, presentation and management of intradural extramedullary spinal lipomas.
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Affiliation(s)
- Sumit Raj
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Pradeep Chouksey
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Rakesh Mishra
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Ashwani Tandon
- Department of Pathology, All India Institute of Medical Sciences, Bhopal, India
| | - Manas Prakash
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
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Morota N, Ihara S, Inukai M, Kuroha S. Ventral anchoring of the conus medullaris: a new surgical technique preventing the radiographic recurrence of retethering after surgery for tethered spinal cord. Childs Nerv Syst 2023; 39:3147-3154. [PMID: 37115276 DOI: 10.1007/s00381-023-05972-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Retethering is not an unusual operation for a congenital lumbosacral dysraphic spinal lesion. The present study aimed to assess a new surgical technique for preventing retethering. SURGICAL TECHNIQUE After untethering the spinal cord, the pia mater or scar tissue at the caudal end of the conus medullaris is anchored to the ventral dura mater loosely using 8-0 thread, and the dura mater is closed directly. This technique is called ventral anchoring. RESULTS Ventral anchoring was performed in 15 patients (aged 5 to 37 years old, average age: 12.1 years old) between 2014 and 2021. All but one patient showed improvement or stabilization of the preoperative symptoms. No complication directly related to the procedure was observed. Postoperative MRI demonstrated that the dorsal subarachnoid space was restored in 14 patients but was undetectable or absent in three patients on follow-up MRI. No patients have experienced a recurrence of the tethered cord syndrome during the follow-up period. CONCLUSION Ventral anchoring is effective for restoring the dorsal subarachnoid space after untethering the spinal cord. This preliminary study suggested that ventral anchoring has the potential to prevent the postoperative radiographic recurrence of tethered spinal cord in patients with a congenital lumbosacral dysraphic spinal lesion.
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Affiliation(s)
- N Morota
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan.
| | - S Ihara
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - M Inukai
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - S Kuroha
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
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Aoki H, Mugikura S, Shirane R, Hayashi T, Kimiwada T, Sakai K, Ainoya K, Ota H, Takase K, Shimanuki Y. Role of Magnetic Resonance Imaging in the Screening of Closed Spinal Dysraphism. Neurol Med Chir (Tokyo) 2023; 63:473-481. [PMID: 37648539 PMCID: PMC10687668 DOI: 10.2176/jns-nmc.2023-0002] [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: 01/11/2023] [Accepted: 06/14/2023] [Indexed: 09/01/2023] Open
Abstract
Closed spinal dysraphism (CSD) encompasses a heterogeneous group of spinal cord deformities, which can be accompanied by several types of skin stigmata. These skin stigmata may include inconspicuous features, such as sacral dimples and deformed gluteal clefts, but the association between such mild skin stigmata and CSD is uncertain. This study aimed to reevaluate the indication for magnetic resonance imaging (MRI) in patients with skin stigmata while considering the indication for surgery. A retrospective analysis was conducted on magnetic resonance images of 1255 asymptomatic children with skin stigmata between 2003 and 2015. Skin stigmata classification was based on medical chart data. All subtypes of CSDs except for filum terminale lipomas (FTL), FTL thicker than 2 mm or with low conus medullaris, were considered to meet the surgical indication. CSD prevalence was estimated while considering the surgical indications and assessed after excluding all FTL cases. Skin stigmata were classified into seven types, dimple, deformed gluteal cleft, hair, subcutaneous mass, appendage, discoloration, and protruding bone, and included 1056 isolated and 199 complex ones. The prevalence of CSD was 19.5%, 6.8%, and 0.5% among patients with isolated dimples (n = 881) and 13.9%, 5.8%, and 0.7% among those with isolated deformed gluteal clefts (n = 136) for all cases, surgical indications, and patients without FTL, respectively. Dimples and deformed gluteal clefts had a low prevalence of CSD requiring surgical intervention, and cases without FTL were rare. Asymptomatic patients with mild skin stigmata may not require immediate MRI.
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Affiliation(s)
- Hidekazu Aoki
- Department of Radiology, Miyagi Children's Hospital
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Shunji Mugikura
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital
| | | | | | | | - Keiko Ainoya
- Department of Urology, Miyagi Children's Hospital
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Hospital
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Morota N, Sakamoto H. Surgery for spina bifida occulta: spinal lipoma and tethered spinal cord. Childs Nerv Syst 2023; 39:2847-2864. [PMID: 37421423 DOI: 10.1007/s00381-023-06024-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023]
Abstract
The technical evolution of the surgery for spina bifida occulta (SBO) over the course of a half-century was reviewed with special foci placed on the spinal lipoma and tethered spinal cord. Looking back through history, SBO had been included in spina bifida (SB). Since the first surgery for spinal lipoma in the mid-nineteenth century, SBO has come to be recognized as an independent pathology in the early twentieth century. A half-century ago, the only option available for SB diagnosis was the plain X-ray, and pioneers of the time persevered in the field of surgery. The classification of spinal lipoma was first described in the early 1970s, and the concept of tethered spinal cord (TSC) was proposed in 1976. Surgical management of spinal lipoma with partial resection was the most widely practiced approach and was indicated only for symptomatic patients. After understanding TSC and tethered cord syndrome (TCS), more aggressive approaches became preferred. A PubMed search suggested that there was a dramatic increase of publications on the topic beginning around 1980. There have been immense academic achievements and technical evolutions since then. From the authors' viewpoint, landmark achievements in this field are listed as follows: (1) establishment of the concept of TSC and the understanding of TCS; (2) unraveling the process of secondary and junctional neurulation; (3) introduction of modern intraoperative neurophysiological mapping and monitoring (IONM) for surgery of spinal lipomas, especially the introduction of bulbocavernosus reflex (BCR) monitoring; (4) introduction of radical resection as a surgical technique; and (5) proposal of a new classification system of spinal lipomas based on embryonic stage. Understanding the embryonic background seems critical because different embryonic stages bring different clinical features and of course different spinal lipomas. Surgical indications and selection of surgical technique should be judged based on the background embryonic stage of the spinal lipoma. As time flows forward, technology continues to advance. Further accumulation of clinical experience and research will open the new horizon in the management of spinal lipomas and other SBO in the next half-century.
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Affiliation(s)
- Nobuhito Morota
- Department of Neurosurgery, Kitasato Universicy Hospital, 1-15-1 Kitasato, Minami-Ku, Sagamihara, 252-0375, Japan.
| | - Hiroaki Sakamoto
- Department of Pediatric Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojima-Hondori, Miyakojima-Ku, Osaka, 534-0021, Japan
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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Sagenly M, Karnoub MA, Vinchon M. Non-dysraphic intramedullary spinal cord lipoma of the child: Report of 3 cases. Neurochirurgie 2023; 69:101473. [PMID: 37482183 DOI: 10.1016/j.neuchi.2023.101473] [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: 04/06/2023] [Revised: 07/02/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND AND PURPOSE Non-dysraphic intramedullary spinal cord lipomas (NDSCL) represent 1% of spinal cord tumors. They are less frequent than dysraphic spinal cord lipomas and clinical presentation is unspecific. There are no guidelines on surgical management. MATERIAL AND METHODS We report three observations of NDSCL in children, focusing on the clinical presentation, surgical management and postoperative outcome. RESULTS The patients, one female and two males, aged from 5 months to 10 years presented with neurological deterioration, pain, spinal rigidity and in two cases, a subcutaneous mass. Spinal MRI found intradural lipomas without spina bifida, located in the cervico-thoracic area in all cases. The lipoma extended to the medulla oblongata in two cases and was in the lumbar region in the third. These lipomas were massive, requiring decompression surgery. Surgery confirmed the lipoma to be subpial. We performed debulking of the lipoma without attempting total resection, and with or without dural plasty and laminoplasty, followed by minerva cast in two cases, and avoidance of standing in the youngest. Satisfactory recovery occurred in all three cases. After a follow-up between 4 months and 9 years, the outcome was favorable in all cases, and no patient presented with secondary spinal deformation or lipoma progression. CONCLUSION NDSCL is a rare entity, which often manifests with progressive pain and neurological deficits. In our experience, partial resection with or without dural plasty and laminoplasty has been associated with satisfactory postoperative outcomes and no recurrence of symptoms. We should be attentive to the risk of postoperative spinal deformity in these young patients.
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Affiliation(s)
- M Sagenly
- Department of pediatric neurosurgery, University of Lille, Lille University Hospital, Lille, France.
| | - M-A Karnoub
- Department of pediatric neurosurgery, University of Lille, Lille University Hospital, Lille, France
| | - M Vinchon
- Department of pediatric neurosurgery, University of Lille, Lille University Hospital, Lille, France
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Kurogi A, Murakami N, Suzuki SO, Shimogawa T, Mukae N, Yoshimoto K, Morioka T. Retained medullary cord and caudal lipoma with histopathological presence of terminal myelocystocele in the epidural stalk. Surg Neurol Int 2023; 14:279. [PMID: 37680925 PMCID: PMC10481812 DOI: 10.25259/sni_479_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/14/2023] [Indexed: 09/09/2023] Open
Abstract
Background The retained medullary cord (RMC), caudal lipoma, and terminal myelocystocele (TMCC) are thought to originate from the failed regression spectrum during the secondary neurulation, and the central histopathological feature is the predominant presence of a central canal-like ependyma-lined lumen (CC-LELL) with surrounding neuroglial tissues (NGT), as a remnant of the medullary cord. However, reports on cases in which RMC, caudal lipoma, and TMCC coexist are very rare. Case Description We present two patients with cystic RMC with caudal lipoma and caudal lipoma with an RMC component, respectively, based on their clinical, neuroradiological, intraoperative, and histopathological findings. Although no typical morphological features of TMCC were noted on neuroimaging, histopathological examination revealed that a CC-LELL with NGT was present in the extraspinal stalk, extending from the skin lesion to the intraspinal tethering tract. Conclusion This histopathological finding indicates the presence of TMCC that could not be completely regressed and further supports the idea that these pathologies can be considered consequences of a continuum of regression failure during secondary neurulation.
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Affiliation(s)
- Ai Kurogi
- Department of Neurosurgery, Fukuoka Children’s Hospital, Fukuoka, Japan
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children’s Hospital, Fukuoka, Japan
| | | | | | - Nobutaka Mukae
- Department of Neurosurgery, Iizuka Hospital, Iizuka, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Kyushu University, Fukuoka, Japan
| | - Takato Morioka
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Japan
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12
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Arjipour M, Ownagh F, Eftekharian M. Fatty syringomyelia mimicking lipoma with spinal cord pilocytic astrocytoma. Neuroradiol J 2023; 36:357-360. [PMID: 36384332 PMCID: PMC10268085 DOI: 10.1177/19714009221140535] [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] [Indexed: 06/04/2024] Open
Abstract
The reporting case is a 27 year-old woman. She was admitted with complaints of clumsy gait and dysesthesia over her upper limbs and spasticity in the legs. The investigations revealed a long segment cervical intramedullary tumor, associated with whole cord syringomyelia. The superior part of syringomyelia image intensity matched intramedullary lipoma completely. C1-C5 intramedullary tumor was resected grossly under microscopic view, and a fat-containing liquid exited the syringomyelia cavity at its superior pole. After a transient paresis just following the surgery, neurological condition was improved. The follow-up imaging showed that the fatty syringomyelia reduced in dimensions. Conclusion. According to this case and another similar case due to instability, it appears that as a rare phenomenon, syringomyelia liquid content sometimes could have fatty droplets which could mimic intramedullary lipoma with an unknown mechanism. It seems these fat droplets in syringomyelia would not change its natural history.
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Affiliation(s)
- Mahdi Arjipour
- Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Farid Ownagh
- Department of Neurosurgery, Hamadan University of Medical Sciences, Hamadan, Iran
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13
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Grasso G, Paolini F, Sallì M, Kim HS, Torregrossa F. Nondysraphic Intramedullary Lipoma of the Cervical Spine: A Systematic Review of Management Strategies and Outcomes. World Neurosurg 2023; 174:197-204.e1. [PMID: 36871652 DOI: 10.1016/j.wneu.2023.02.131] [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: 01/24/2023] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Nondysraphic intramedullary lipomas of the cervical spine are extremely rare, and only a few cases have been reported. We aimed to provide a thorough review of the literature regarding patient characteristics, treatment options, and outcomes in these patients. We also provided an illustrative case from our institution, which we added to the pool of patients identified by our review. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature in PubMed/Medline, Web of Science, and Scopus databases was searched. Nineteen studies were included in the final quantitative analysis. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias. RESULTS We identified 24 patients with nondysraphic cervical intradural intramedullary lipoma of the spinal cord. The patients were predominantly male (70.8%) with a mean age of 30.3 years. Quadriparesis was observed in 33.3% of the cases, while paraparesis occurred in 25% of the patients. Sensory disturbances were observed in 8.3% of the cases. In some patients, the presenting symptoms were neck pain (4.2%) and headache (4.2%). Surgical treatment was performed in 22 cases (91.7%). In 13 cases (54.2%) a subtotal removal was reached, and in 8 cases (33.3%) partial tumor removal was feasible. In 1 case (4.2%) a simple laminectomy was performed. Fourteen patients (58.3%) improved, 6 (25%) were unvaried, and 2 (8.3%) worsened. The mean follow-up was 30.8 months. CONCLUSIONS Overall, surgical treatment can provide substantial spinal cord decompression improving or stabilizing the neurologic deficits. Experience from our case, along with analysis of reports from the literature, suggests that careful and controlled resection may provide benefits and avoid serious complications otherwise that result from aggressive resection.
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Affiliation(s)
- Giovanni Grasso
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy.
| | - Federica Paolini
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Marcello Sallì
- Rehabilitation Medicine Outpatient Department, A.S.P. Palermo, Palermo, Italy
| | - Hyeun-Sung Kim
- Department of Spine Surgery, Nanoori Gangnam Hospital, Seoul, South Korea
| | - Fabio Torregrossa
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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14
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Lim JX, Fong E, Goh C, Ng LP, Merchant K, Low DCY, Seow WT, Low SYY. Fibrofatty filum terminale: long-term outcomes from a Singapore children's hospital. J Neurosurg Pediatr 2023; 31:197-205. [PMID: 36461829 DOI: 10.3171/2022.8.peds22103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE The role of prophylactic detethering a fibrofatty filum terminale (FFT) remains equivocal. Furthermore, long-term studies focusing on urological outcomes are sparse. The aims of this study were to present an institutional experience on the perioperative and long-term outcomes of FFT surgery and to assess for factors that contribute to postoperative clean intermittent catheterization (CIC). METHODS This was a single-institution, retrospective study conducted over a 20-year period. Patients younger than 19 years of age who underwent surgery for FFT were included. Variables of interest included patient demographics, clinical presentation, radiological findings, postoperative complications, and long-term need for CIC. Outcomes were measured using the Necker functional score and modified Hoffer Functional Ambulation scale score at 3, 6, and 12 months postdischarge. RESULTS A total of 164 surgeries were performed for FFT from 2000 to 2020. The median age at surgery was 1.1 years, and the mean follow-up duration was 8.3 years. There were 115 patients (70.1%) who underwent prophylactic-intent surgery and 49 patients (29.9%) who underwent therapeutic-intent surgery. The proportion of therapeutic-intent surgeries increased significantly with age percentiles (0-20th, 21.9%; 20th-40th, 9.1%; 40th-60th, 18.2%; 60th-80th, 36.4%; and 80th-100th, 63.6% [p < 0.001]). Thirty patients (18.3%) had an associated syndrome, the most common (n = 19, 11.6%) being VACTERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities). Forty-eight patients (29.3%) had an associated malformation (anorectal anomaly = 37, urogenital anomaly = 16, and sacral anomaly = 3). Cutaneous manifestation was the most common presentation (n = 96, 58.5%), followed by lower-limb neurological deficits (n = 21, 12.8%). A low-lying conus was present in 36.0% of patients (n = 59), and 16.5% had an associated syrinx (n = 27). There were 26 patients (18.8%) with an abnormal preoperative urodynamic study. Three patients (1.8%) had postoperative complications that required repeat surgery. There were no cases of CSF leakage. One patient (0.6%) developed retethering requiring another surgery. Postoperative CIC was required in 11 patients (6.7%). Multivariable analyses showed that an abnormal preoperative urodynamic study (adjusted OR 5.5 [95% CI 1.27-23.9], p = 0.023) and having an intraspinal syrinx (adjusted OR 5.29 [95% CI 1.06-26.4], p = 0.042) were associated with the need for CIC. CONCLUSIONS The authors' results demonstrate that detethering surgery for FFT is a relatively safe procedure and can be performed prophylactically. Nonetheless, the risks of postoperative CIC should be emphasized during the preoperative counseling process.
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Affiliation(s)
- Jia Xu Lim
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Elizabeth Fong
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Cheryl Goh
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Lee Ping Ng
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Khurshid Merchant
- 2Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore
| | - David C Y Low
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
- 3Department of Neurosurgery, National Neuroscience Institute, Singapore
- 4Neuroscience Academic Clinical Program, SingHealth Duke-NUS, Singapore; and
| | - Wan Tew Seow
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
- 3Department of Neurosurgery, National Neuroscience Institute, Singapore
- 4Neuroscience Academic Clinical Program, SingHealth Duke-NUS, Singapore; and
| | - Sharon Y Y Low
- 1Neurosurgical Service, KK Women's and Children's Hospital, Singapore
- 3Department of Neurosurgery, National Neuroscience Institute, Singapore
- 4Neuroscience Academic Clinical Program, SingHealth Duke-NUS, Singapore; and
- 5Paediatrics Academic Clinical Program, SingHealth Duke-NUS, Singapore
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15
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Lee JS, Kim YM, Chae SA, Kim SK, Phi JH. Pediatric Nondysraphic Intramedullary Lipoma : Report of Two Cases and Review of the Literature. J Korean Neurosurg Soc 2023; 66:211-218. [PMID: 36071566 PMCID: PMC10009248 DOI: 10.3340/jkns.2022.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022] Open
Abstract
Pediatric nondysraphic intramedullary lipoma is very rare, and only limited cases have been reported. In the present case, we present two infant patients with these pathologies who were surgically treated. Previous literature on 20 patients with these diseases who had undergone surgical treatments was analyzed. Surgical treatment should be considered in most symptomatic patients, and laminoplastic laminotomy and internal debulking of the lipoma under intraoperative neurophysiological monitoring are mostly recommended.
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Affiliation(s)
- Jong Seok Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Mi Kim
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine and Biochemical Research Institute, Busan, Korea
| | - Soo Ahn Chae
- Department of Pediatrics, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hoon Phi
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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16
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Murakami N, Kurogi A, Suzuki SO, Akitake N, Shimogawa T, Mukae N, Yoshimoto K, Morioka T. Ectopic dorsal root ganglion in cauda equina mimicking schwannoma in a child. Surg Neurol Int 2023; 14:33. [PMID: 36895208 PMCID: PMC9990762 DOI: 10.25259/sni_1089_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023] Open
Abstract
Background A heterotopic dorsal root ganglion (DRG) is sometimes observed in the vicinity of dysplastic neural structures during surgery for open spinal dysraphism; however, it is rarely associated with closed spinal dysraphism. Distinguish from neoplasms by preoperative imaging study is difficult. Although the embryopathogenesis of a heterotopic DRG has been speculated to be migration disorder of neural crest cells from primary neural tube, its details remain unelucidated. Case Description We report a pediatric case with an ectopic DRG in cauda equina associated with a fatty terminal filum and bifid sacrum. The DRG mimicked a schwannoma in the cauda equina on preoperative magnetic resonance imaging. Laminotomy at L3 revealed that the tumor was entangled in the nerve roots, and small parts of the tumor were resected for biopsy. Histopathologically, the tumor consisted of ganglion cells and peripheral nerve fibers. Ki-67 immunopositive cells were observed at the periphery of the ganglion cells. These findings indicate the tumor comprised DRG tissue. Conclusion We report detailed neuroradiological, intraoperative and histological findings and discuss the embryopathogenesis of the ectopic DRG. One should be aware of the possibility of ectopic or heterotopic DRGs when cauda equina tumors are observed in pediatric patients with neurulation disorders.
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Affiliation(s)
- Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ai Kurogi
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | | | - Naoko Akitake
- Department of Urology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Iizuka Hospital, Iizuka, Japan
| | - Koji Yoshimoto
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takato Morioka
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Japan
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17
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Pasquali C, Basaldella F, Sala F. Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism. Adv Tech Stand Neurosurg 2023; 47:235-272. [PMID: 37640878 DOI: 10.1007/978-3-031-34981-2_9] [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] [Indexed: 08/31/2023]
Abstract
Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.
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Affiliation(s)
- Claudia Pasquali
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Federica Basaldella
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy
| | - Francesco Sala
- Section of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University Hospital, Verona, Italy.
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18
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Abraham AP, Vora TK, Selvi BT, Rajshekhar V. Characterizing syringomyelia and its clinical significance in 140 patients with lipomyelomeningocele. J Neurosurg Pediatr 2022; 30:349-356. [PMID: 35901676 DOI: 10.3171/2022.6.peds2286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aims of this study were to characterize syringomyelia in patients with lipomyelomeningocele (LMMC) and investigate the association between the presence of a syrinx and patient neurological deficits. METHODS Patients with LMMC who had been admitted between 2007 and 2020 were included in the study. Syringomyelia on magnetic resonance imaging (MRI) was classified into three groups: true syrinx, early syrinx, and presyrinx. The correlation of clinical deficits (at birth, new onset, and progressive) and type of lipoma with the presence and type of syrinx was studied. RESULTS Among a total of 140 patients, the median age was 2.5 (IQR 1.3-9) years. Neurological deficits were present at birth in 75 (53.6%) patients, but 67 (47.9%) had new-onset deficits or progression of their birth deficits. The most common type of spinal lipoma was the transitional type (75.7%). Thirty-nine (27.9%) patients had a syrinx (37 with a true syrinx, 2 with an early syrinx), and 25 (17.9%) patients had a presyrinx. There was no significant correlation between the presence of a syrinx and patient neurological deficits. However, patients with a syrinx that was not adjacent to the lipoma (≥ 1 vertebral level away) had a higher incidence of deficits at birth (p = 0.045), whereas those with a syrinx spanning ≥ 5 vertebral levels had a higher incidence of progressive neurological deficits (p = 0.04). Six (75%) of 8 patients in whom serial MRI had shown syrinx progression had clinical worsening. CONCLUSIONS Syrinx location with respect to the spinal lipoma, syrinx length, and progressive syringomyelia may have clinical significance in patients with LMMC.
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Affiliation(s)
| | | | - Bernice T Selvi
- 2Radiology, Christian Medical College, Vellore, Tamil Nadu, India
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19
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Embryopathological relationship between retained medullary cord and caudal spinal lipoma. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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20
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De Vloo P, Sharma J, Alderson L, Jankovic I, Tahir MZ, Desai D, Pang D, Thompson DNP. Radical resection of lumbosacral lipomas in children: the Great Ormond Street Hospital experience. Childs Nerv Syst 2022; 38:1113-1123. [PMID: 35262755 DOI: 10.1007/s00381-022-05483-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 02/28/2022] [Indexed: 12/18/2022]
Abstract
PURPOSE In 2009, Pang described a radical resection technique for congenital lumbosacral lipomas, with lower long-term symptomatic re-tethering rates compared with partial resections and conservative management, and low surgical morbidity. We adopted this technique in 2011, and aim to describe our first results. METHODS In this monocentric retrospective audit, we included dorsal, transitional, chaotic, and caudal-type lumbosacral lipomas. Exclusion criteria were previously operated lipomas, pure filar lipomas, and concomitant major congenital anatomical urogenital/gastrointestinal abnormalities. Neuro-uro-orthopaedic status at presentation and at three months, one year and last postoperative follow-up, intraoperative electrophysiology, and extent of resection were collected. RESULTS From January 2011 to September 2019, 91 patients were operated (median age 2y2m; 63 transitional; 14 caudal; 8 dorsal; 6 chaotic). Preoperatively, 67% were symptomatic. Preoperative and one-year postoperative rates of impaired ambulation (44% to 43%), hypoesthesia (8% to 5%), urodynamic/uroradiological abnormalities (49% to 37%), and foot/ankle deformities (8% to 5%) were comparable, whilst pain improved (25% to 5%) but catheterisation rates increased (21% to 36%). 23/92 (25%) suffered wound-related complications. 2/91 (2%) developed symptomatic re-tethering requiring second surgery. Mean cord/sac ratio was 0.47. 43% had > 20 mm3 residual fat, which improved with increasing surgical experience. CONCLUSION Radical lipoma resection, guided by intraoperative neuromonitoring, with reconstruction of the neural placode and expansion duraplasty is technically feasible and results in low rates of late deterioration and re-tethering. Lipoma-type and pre-operative status are important outcome predictors. Operative risks are not insignificant. Future studies need to determine appropriate selection criteria for surgery.
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Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK. .,Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium.
| | - Julia Sharma
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.,Department of Neurosurgery, Valley Childrens Hospital, Madera, CA, USA
| | - Lucy Alderson
- Department of Physiotherapy, Great Ormond Street Hospital for Children, London, UK
| | - Ivana Jankovic
- Department of Neurophysiology, Great Ormond Street Hospital for Children, London, UK
| | - M Zubair Tahir
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.,Institute of Child Health, University College London, London, UK
| | - Divyesh Desai
- Department of Physiotherapy, Great Ormond Street Hospital for Children, London, UK.,Department of Urology, Great Ormond Street Hospital for Children, London, UK
| | - Dachling Pang
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.,Department of Physiotherapy, Great Ormond Street Hospital for Children, London, UK
| | - Dominic N P Thompson
- Department of Neurosurgery, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.,Department of Physiotherapy, Great Ormond Street Hospital for Children, London, UK
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21
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Kurogi A, Murakami N, Mukae N, Shimogawa T, Goto K, Shono T, Suzuki SO, Yoshimoto K, Morioka T. Congenital dermal sinus and filar lipoma located in close proximity at the dural cul-de-sac mimicking limited dorsal myeloschisis. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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22
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Morizawa Y, Satoh H, Arai M, Iwasa S, Sato A, Fujimoto K. Urodynamics findings pre- and post-untethering surgery in children with filum lipoma: A single-institution experience. Int J Urol 2022; 29:884-889. [PMID: 35596566 DOI: 10.1111/iju.14931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/27/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We aimed to investigate the changes in urodynamics and voiding cystourethrogram parameters on pre- and post-untethering surgery in patients aged under 2 years with filum lipoma. METHODS Sixty-two patients were enrolled in this study. The changes in urodynamics and voiding cystourethrogram parameters were compared before untethering surgery and 6 months after untethering surgery. These parameters were bladder volume, bladder deformity, vesicoureteral reflux during voiding cystourethrogram, detrusor overactivity, bladder compliance, and post-void residual volume in urodynamics. RESULTS Bladder volume during voiding cystourethrogram and bladder compliance increased significantly from 89.8 ± 49.5 mL to 114.5 ± 50.5 mL (P = 0.0069) and 10.2 ± 6.2 mL/mmH2 O to 17.0 ± 13.3 mL/mmH2 O (P = 0.0008), respectively, at 6-month follow-up. Six patients required combination management with clean intermittent catheterization at 25.1 ± 8.2 months (14.3 ± 6.5-months follow-up) because of elevated post-void residual volumes. CONCLUSIONS According to voiding cystourethrogram results, bladder function and urodynamics in patients with filum lipoma significantly improved after untethering surgery. Non-invasive assessment based on measurements of post-void residual should be considered as a postoperative follow-up method.
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Affiliation(s)
- Yosuke Morizawa
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroyuki Satoh
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masashi Arai
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shun Iwasa
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Atsuko Sato
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
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23
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Yoshifuji K, Morota N, Omori Y, Koyanagi I, Mikuni N. Physiological rapid growth of spinal lipoma in the early postnatal period. J Neurosurg Pediatr 2022:1-9. [PMID: 35276650 DOI: 10.3171/2022.1.peds21474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal lipomas are congenital malformations. They do not express tumorous growth but are found to increase in volume like other normal subcutaneous fat tissue during the early postnatal period. To understand the natural course of volume changes in spinal lipomas, the authors measured the changes in size of spinal lipomas together with the normal subcutaneous fat in relation to BMI. METHODS A total of 27 patients with conus spinal lipoma excluding lipomyelomeningocele who underwent MRI twice before surgery (on initial diagnosis and immediately preoperatively) were included. Patients' ages at the time of the first MRI ranged from 0 to 32 months (mean 2.9 months, median 1 month). Candidates were categorized by age into three groups: < 1 month, 1-2 months, and ≥ 3 months. The growth rate of the spinal lipomas (in three directions), change in thickness of the normal subcutaneous fat, growth rate of the normal spinal canal (dorsoventral direction), and change in BMI were retrospectively analyzed between the three groups. RESULTS The mean interval between MRI studies was 83.1 days. During this time, the mean lipoma growth rates were 199%, 149%, and 133% in the dorsoventral, lateral, and craniocaudal directions, respectively (with 100% representing the first measurement). The mean change in the thickness of the normal subcutaneous fat was 183%. The mean growth of the normal spinal canal was 111%. The mean increase in BMI was 124%. These rates were all significantly higher in the younger groups. There was no significant difference in the growth rates between the lipoma and the subcutaneous fat in every age group. In contrast, the growth rate of the lipoma significantly exceeded that of the spinal canal in patients younger than 3 months. The subarachnoid space around the lipoma became obstructed in 35.3%, and spinal cord distortion occurred in 48.1% of the patients younger than 3 months. CONCLUSIONS Spinal lipomas rapidly increase in volume before the age of 3 months and especially in infants younger than 1 month. Their features closely correlate with the physiological growth of the normal subcutaneous fat and the increase in BMI. The rapid growth of lipomas suggests the importance of close observation in this period, keeping in mind the typical anatomical changes of lipomas and their surrounding structures.
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Affiliation(s)
- Kazuhisa Yoshifuji
- 1Division of Pediatric Neurosurgery, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Nobuhito Morota
- 2Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Yoshinori Omori
- 1Division of Pediatric Neurosurgery, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Izumi Koyanagi
- 3Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan; and
| | - Nobuhiro Mikuni
- 4Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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24
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Yang J, Lee JY, Kim KH, Yang HJ, Wang KC. Disorders of Secondary Neurulation: Suggestion of a New Classification According to Pathoembryogenesis. Adv Tech Stand Neurosurg 2022; 45:285-315. [PMID: 35976454 DOI: 10.1007/978-3-030-99166-1_9] [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] [Indexed: 06/15/2023]
Abstract
Recently, advanced knowledge on secondary neurulation and its application to the clinical experience have led to the deeper insight into the pathoembryogenesis of secondary neurulation with new classifications of the caudal spinal dysraphic entities. Here, we summarize the dynamic changes in the concepts of disordered secondary neurulation over the last two decades. In addition, we suggest our new pathoembryogenetic explanations for a few entities based on the literature and the data from our previous animal research. Disordered secondary neurulation at each phase may cause various corresponding lesions, such as (1) failed junction with the primary neural tube (junctional neural tube defect and segmental spinal dysgenesis), (2) dysgenesis or duplication of the caudal cell mass associated with disturbed activity of caudal mesenchymal tissue (caudal agenesis and caudal duplication syndrome), (3) abnormal continuity of medullary cord to the surrounding layers, namely, failed ingression of the primitive streak to the caudal cell mass (myelomeningocele), focal limited dorsal neurocutaneous nondisjunction (limited dorsal myeloschisis and congenital dermal sinus), and neuro-mesenchymal adhesion (lumbosacral lipomatous malformation), and (4) regression failure spectrum of the medullary cord (thickened filum and filar cyst, retained medullary cord and low-lying conus, terminal myelocele, and terminal myelocystocele). It seems that almost every anomalous entity of the primary neural tube may occur in the area of secondary neurulation. Furthermore, the close association of the caudal cell mass with the activity of caudal mesenchymal tissue involves a wider range of surrounding structures in secondary neurulation than in primary neurulation. Although the majority of the data are from animals and many theories are still conjectural, these changing concepts of normal and disordered secondary neurulation will provoke further advancements in our management strategies as well as in the pathoembryogenetic understanding of anomalous lesions in this area.
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Affiliation(s)
- Jeyul Yang
- Neuro-Oncology Clinic, Center for Rare Cancers, National Cancer Center, Goyang, Kyounggi-do, South Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, South Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hee Jin Yang
- Department of Neurosurgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Kyu-Chang Wang
- Neuro-Oncology Clinic, Center for Rare Cancers, National Cancer Center, Goyang, Kyounggi-do, South Korea.
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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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Hayashi T, Kimiwada T, Shirane R, Tominaga T. Retethering risk in pediatric spinal lipoma of the conus medullaris. J Neurosurg Pediatr 2021:1-8. [PMID: 34798614 DOI: 10.3171/2021.9.peds21413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lipoma of the conus medullaris (LCM) causes neurological symptoms known as tethered cord syndrome (TCS). The symptoms can be seen at diagnosis and during long-term follow-up. In this report, pediatric patients with LCMs who underwent untethering surgery, under the policy of performing surgery if diagnosed regardless of symptoms, were retrospectively reviewed to evaluate long-term surgical outcomes. Possible risk factors for retethered cord syndrome (ReTCS) were evaluated in the long-term follow-up period. METHODS A total of 51 consecutive pediatric patients with LCMs who underwent a first untethering surgery and were followed for > 100 months were retrospectively analyzed. The surgery was performed with the partial removal technique. Pre- and postoperative clinical and radiological data were reviewed to analyze the outcomes of surgery and identify potential risk factors for ReTCS. RESULTS During follow-up, 12 patients experienced neurological deterioration due to ReTCS. The overall 10-year and 15-year progression-free survival rates were 82.3% and 75.1%, respectively. On univariate analysis, a lipoma type of lipomyelomeningocele (OR 11, 95% CI 2.50-48.4; p = 0.0014), patient age at the time of surgery (OR 0.41, 95% CI 0.14-1.18; p = 0.0070), and the mean patient growth rate after surgery (OR 2.00, 95% CI 1.12-3.41; p = 0.0040) were significant factors associated with ReTCS. Cox proportional hazard models showed that a lipoma type of lipomyelomeningocele (HR 5.16, 95% CI 1.54-20.1; p = 0.010) and the mean growth rate after surgery (HR 1.88, 95% CI 1.00-3.50; p = 0.040) were significantly associated with the occurrence of ReTCS. CONCLUSIONS More complex lesions and a high patient growth rate after surgery seemed to indicate increased risk of ReTCS. Larger prospective studies and registries are needed to define the risks of ReTCS more adequately.
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Affiliation(s)
- Toshiaki Hayashi
- 1Department of Neurosurgery, Miyagi Children's Hospital, Sendai; and
| | - Tomomi Kimiwada
- 1Department of Neurosurgery, Miyagi Children's Hospital, Sendai; and
| | - Reizo Shirane
- 1Department of Neurosurgery, Miyagi Children's Hospital, Sendai; and
| | - Teiji Tominaga
- 2Tohoku University Graduate School of Medicine, Sendai, Japan
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27
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Morioka T, Murakami N, Suzuki SO, Mukae N, Shimogawa T, Kurogi A, Shono T, Mizoguchi M. Surgical histopathology of a filar anomaly as an additional tethering element associated with closed spinal dysraphism of primary neurulation failure. Surg Neurol Int 2021; 12:373. [PMID: 34513140 PMCID: PMC8422463 DOI: 10.25259/sni_340_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/09/2021] [Indexed: 11/12/2022] Open
Abstract
Background: Closed spinal dysraphism of primary neurulation failure could be associated with filar anomalies, such as filar lipoma or thickened and tight filum terminale (TFT), resulting from impaired secondary neurulation. Retained medullary cord (RMC) is a remnant of the cavitary medullary cord originating from the secondary neurulation failure. Some filar lipomas are known to contain a central canal-like ependyma-lined lumen with surrounding neuroglial tissues (E-LC w/NGT), that is, a characteristic histopathology of RMC. To clarify the embryological background of these filar anomalies, we evaluated the histopathological findings. Methods: Among 41 patients with lesions of primary neurulation failure who underwent initial untethering surgery, the filum including cord-like structure (C-LS) was additionally resected in 10 patients (five dorsal and transitional lipomas; five limited dorsal myeloschisis). We retrospectively analyzed the clinical, neuroradiological, intraoperative, and histopathological findings. Results: Among 10 patients, two patients were diagnosed with RMC based on morphological features and intraoperative neurophysiological monitoring. The diagnosis of filar lipoma was made in six patients, since various amounts of fibroadipose tissue were histopathologically noted in the filum. Two patients were diagnosed with TFT, since the filum was composed solely of fibrocollagenous tissue. E-LC w/NGT was noted not only in both C-LSs of RMCs but also in two out of six fila both with filar lipomas and fila with TFTs. Conclusion: These findings provide further evidence for the idea that entities, such as filar lipoma, TFT, and RMC, can be considered consequences of a continuum of regression failure occurring during late secondary neurulation.
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Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan.,Department of Neurosurgery, Harasanshin Hospital, Karatsu, Saga
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | | | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka, Japan
| | | | - Ai Kurogi
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Tadahisa Shono
- Department of Neurosurgery, Harasanshin Hospital, Karatsu, Saga
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka, Japan
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28
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Kumar N, Chatur C, Balani A, Bisharat M, Tahir Z, Johal N, Sudhakar S, Cuckow P, Thompson DNP, Mankad K. Patterns of spinal cord malformation in cloacal exstrophy. J Neurosurg Pediatr 2021; 28:236-243. [PMID: 34087792 DOI: 10.3171/2021.1.peds20648] [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: 07/26/2020] [Accepted: 01/04/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to assess the prevalence and spectrum of spinal dysraphism in a cohort of children with cloacal exstrophy (CEX) using MRI. METHODS Children with CEX presenting between 1999 and 2019 with baseline spinal MRI were included. The images were reviewed in consensus to assess the type of dysraphism. The dysraphisms were initially reviewed and described based on their descriptive anatomy, and then classified according to anomalies of gastrulation, primary neurulation, or secondary neurulation. RESULTS Thirty-four children were included. Thirty-three of these children had closed spinal dysraphism, and 1 had a normal spine. Of the 33 cases of closed spinal dysraphism, the conus and/or filum terminale were involved in all cases. The most common malformations were spinal lipoma (n = 20) and terminal myelocystocele (n = 11). The lipomas were heterogeneous: 4 dorsal, 9 transitional, 4 chaotic, and 3 terminal. A large subgroup (10/20, 50%) within the lipomas had an unusual morphology of noncontiguous double lipomas, the proximal fat related to the conus and the distal fat within the filum. These were difficult to characterize using existing classifications. In 2 cases, only a thickened filum was noted. The majority of these malformations were compatible with a disorder of secondary neurulation. CONCLUSIONS Complex spinal dysraphisms are consistently associated with CEX. The unusual dysraphism patterns found in this group of patients highlight the limitations of current embryological classifications. Given the propensity for neurological deterioration in this group of patients, spinal MRI should be routinely performed. The type and distribution of malformations seen have implications for the wider understanding of the pathogenesis and classification of lumbosacral lipomas.
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Affiliation(s)
| | | | | | | | - Zubair Tahir
- 3Pediatric Neurosurgery, Great Ormond Street Hospital, London, United Kingdom
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29
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Thompson DNP, Spoor J, Schotman M, Maestri S, Craven CL, Desai D. Does conus morphology have implications for outcome in lumbosacral lipoma? Childs Nerv Syst 2021; 37:2025-2031. [PMID: 33604718 DOI: 10.1007/s00381-021-05081-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/08/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Lumbosacral lipomas (LSL) of the 'dorsal' type have been associated with more favourable outcomes compared with other conus region lipomas. We hypothesised that integrity of the conus on MRI underpins the improved prognosis in this subgroup of LSL patients. METHODS The definition of 'dorsal lipomas' included lipomas with attachment to the conus, but where the conus could be delineated on MRI (Morota type 1) as reported by Morota et al. (J Neurosurg Pediatr 19:428-439, 2017). Additional inclusion criteria included asymptomatic status at presentation, age >3 years at follow-up, and neurological and urological evaluation at presentation and at last follow-up. Lipoma extent and conus level were recorded. Outcome measures were the need for untethering surgery and neuro-urological status at last follow-up. Urological outcomes were defined by continence and efficacy of bladder emptying. RESULTS Twenty-six children were included (median age 8.7 years). Conus level was low (at or below L2) in 92%. Nine required untethering surgery: 5 prophylactic, 4 because of clinical deterioration. Twenty-five children were continent at last follow-up, one had stress incontinence, and none required catheterisation. One had persisting ankle weakness after surgery requiring orthotic support. CONCLUSIONS In LSL of the conus, visualisation of the conus on MRI is associated with good urological and motor outcomes. The integrity of the conus appears to be a more important prognostic factor than anatomical level. An observational approach to this group of LSL patients does not appear to compromise outcomes. These findings support a selective approach to untethering surgery.
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Affiliation(s)
- Dominic N P Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | - Jochem Spoor
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Department of Paediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martje Schotman
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Department of Urology, Haga Hospitals, The Hague, The Netherlands
| | - Susan Maestri
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Claudia L Craven
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Divyesh Desai
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, UK
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30
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Yoshifuji K, Omori Y, Morota N. Physiological defects of lumbosacral vertebral arches on computed tomography images in children. Childs Nerv Syst 2021; 37:1965-1971. [PMID: 33438087 DOI: 10.1007/s00381-021-05040-y] [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: 11/10/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Physiological midline defects of the lumbosacral vertebral arches on radiographs must be distinguished from pathological spina bifida. To date, however, this has not been examined, except for some reports based on plain radiography. The aim of this study is to accurately define the rate and distribution of physiological defects by computed tomography (CT) imaging. METHODS A total of 115 patients aged 0 months to 16 years (median age, 4 years) who underwent CT scans for abdominopelvic disorder not involving the lumbosacral spine were retrospectively analyzed. The lumbosacral spines were collaterally identified on these images. RESULTS In the lumbosacral spine excluding the sacral hiatus, the rate of physiological defects was 66.1% (95% confidence interval [CI]: 56.7-74.7%), and the mean number of defective vertebral arches was 1.6 per patient (95% CI: 1.3-1.9). The rate and mean number of defects were significantly higher in the group of patients less than 6 years old (84.3%, 2.2/patient) than that of patients 6 years old or older (37.8%, 0.5/patient) (p < 0.001 and p < 0.001, respectively). The defect rates by spinal level were S3 (57.4%), S1 (47.8%), S2 (34.8%), L5 (13.0%), L4 (2.6%), and L3 (0.9%) in descending order. CONCLUSIONS Physiological defects were found more commonly at an earlier age and predominantly existed adjacent to the sacral hiatus (S3) and around S1. Understanding the detection rate and distribution features of defects more precisely on CT images will contribute clinically supportive information to distinguish between physiological defects and pathological spina bifida.
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Affiliation(s)
- Kazuhisa Yoshifuji
- Division of Pediatric Neurosurgery, Hokkaido Medical Center for Child Health and Rehabilitation, 1-1-240-6 Kanayama, Teine-ku, Sapporo, 006-0041, Japan.
| | - Yoshinori Omori
- Division of Pediatric Neurosurgery, Hokkaido Medical Center for Child Health and Rehabilitation, 1-1-240-6 Kanayama, Teine-ku, Sapporo, 006-0041, Japan
| | - Nobuhito Morota
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan
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31
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Nonaka M, Ueno K, Isozaki H, Kamei T, Takeda J, Asai A. Familial tendency in patients with lipoma of the filum terminale. Childs Nerv Syst 2021; 37:1641-1647. [PMID: 33415512 DOI: 10.1007/s00381-021-05037-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/03/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Lipoma of the filum terminale (FL) is an abnormality in which fat is deposited in the filum terminale. This lipoma is often detected by skin abnormalities in the lumbosacral area such as a sacrococcygeal dimple. Some cases may develop tethered cord and become symptomatic. However, the genetic basis of FL is still unclear. METHODS This study aimed to determine whether there was a family history of FL or other forms of spina bifida among 54 families of 56 patients with FL and to examine whether there is a familial predisposition in FL. In addition, sex, age at diagnosis, presence of symptoms, presence of sacrococcygeal dimple, and the level of conus medullaris between familial and spontaneous cases were evaluated. RESULTS Of the 54 families of FL patients, there were 48 siblings. Among the 48 siblings, 2 had "occult" FL. The frequency of FL among siblings was estimated to be 4.2% (2/48), which was significantly higher than the sum of previously reported cases of spontaneous FL (0.91%; p = 0.017). However, there was no significant difference in sex, age at diagnosis, presence of symptoms, presence of sacrococcygeal dimple, diameter of filum terminale, or level of conus medullaris between familial and spontaneous cases. CONCLUSION To our knowledge, this is the first report on familial FL and examination of the frequency of FL among siblings. The high probability of FL among siblings of FL patients suggests that genetic factors may play a role in FL development.
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Affiliation(s)
- Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata City, Osaka, 573-1010, Japan.
| | - Katsuya Ueno
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata City, Osaka, 573-1010, Japan
| | - Haruna Isozaki
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata City, Osaka, 573-1010, Japan
| | - Takamasa Kamei
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata City, Osaka, 573-1010, Japan
| | - Junichi Takeda
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata City, Osaka, 573-1010, Japan
| | - Akio Asai
- Department of Neurosurgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata City, Osaka, 573-1010, Japan
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32
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Yang J, Lee JY, Kim KH, Wang KC. Disorders of Secondary Neurulation : Mainly Focused on Pathoembryogenesis. J Korean Neurosurg Soc 2021; 64:386-405. [PMID: 33906343 PMCID: PMC8128515 DOI: 10.3340/jkns.2021.0023] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/16/2021] [Indexed: 12/22/2022] Open
Abstract
Recent advancements in basic research on the process of secondary neurulation and increased clinical experience with caudal spinal anomalies with associated abnormalities in the surrounding and distal structures shed light on further understanding of the pathoembryogenesis of the lesions and led to the new classification of these dysraphic entities. We summarized the changing concepts of lesions developed from the disordered secondary neurulation shown during the last decade. In addition, we suggested our new pathoembryogenetic explanations for a few entities based on the literature and the data from our previous animal research. Disordered secondary neurulation at each phase of development may cause corresponding lesions, such as failed junction with the primary neural tube (junctional neural tube defect and segmental spinal dysgenesis), dysgenesis or duplication of the caudal cell mass associated with disturbed activity of caudal mesenchymal tissue (caudal agenesis and caudal duplication syndrome), failed ingression of the primitive streak to the caudal cell mass (myelomeningocele), focal limited dorsal neuro-cutaneous nondisjunction (limited dorsal myeloschisis and congenital dermal sinus), neuro-mesenchymal adhesion (lumbosacral lipomatous malformation), and regression failure spectrum of the medullary cord (thickened filum and filar cyst, low-lying conus, retained medullary cord, terminal myelocele and terminal myelocystocele). It seems that almost every anomalous entity of the primary neural tube may occur in the area of secondary neurulation. Furthermore, the close association with the activity of caudal mesenchymal tissue in secondary neurulation involves a wider range of surrounding structures than in primary neurulation. Although the majority of the data are from animals, not from humans and many theories are still conjectural, these changing concepts of normal and disordered secondary neurulation will provoke further advancements in our management strategies as well as in the pathoembryogenetic understanding of anomalous lesions in this area.
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Affiliation(s)
- Jeyul Yang
- Neuro-oncology Clinic, Center for Rare Cancers, National Cancer Center, Goyang, Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea.,Department of Anatomy, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyu-Chang Wang
- Neuro-oncology Clinic, Center for Rare Cancers, National Cancer Center, Goyang, Korea
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33
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Morioka T, Murakami N, Suzuki SO, Nakamura R, Mizoguchi M. Subpial Lumbar Lipoma Associated with Retained Medullary Cord. NMC Case Rep J 2021; 8:51-55. [PMID: 34012749 PMCID: PMC8116927 DOI: 10.2176/nmccrj.cr.2020-0073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/08/2020] [Indexed: 11/20/2022] Open
Abstract
Subpial lipomas, which are also known as nondysraphic intramedullary spinal cord lipomas, are not associated with spinal dysraphism resulting from the failed primary neurulation. Retained medullary cord (RMC) is a newly defined entity of closed spinal dysraphism that originates from the late arrest of secondary neurulation. We treated a 6-year-old boy presented with myoclonus of the lower limbs, who had subpial lipoma at the lumbar cord, just rostral to the low-lying conus, which was tethered by a cord-like structure (C-LS) continuous from the conus and extending to the dural cul-de-sac. Following cord untethering from C-LS and minimal debulking of the lipoma, the myoclonus was improved. Histological examination of C-LS revealed a large central canal-like structure in the neuroglial core and the diagnosis of RMC was made. Subpial lipomas can be incidentally coexistent with spinal dysraphism resulting from the failed secondary neurulation, such as RMC.
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Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, Fukuoka, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Ryoko Nakamura
- Department of Pediatrics, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kitakyushu, Fukuoka, Japan
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
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34
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Kurogi A, Murakami N, Morioka T, Mukae N, Shimogawa T, Kudo K, Suzuki SO, Mizoguchi M. Two cases of retained medullary cord running parallel to a terminal lipoma. Surg Neurol Int 2021; 12:112. [PMID: 33880217 PMCID: PMC8053431 DOI: 10.25259/sni_626_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/08/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Retained medullary cord (RMC) is a newly defined entity believed to originate from the late arrest of secondary neurulation. Some RMCs contain varying amounts of lipomatous tissues, which need to be differentiated from spinal lipomas, such as filar and caudal lipomas (terminal lipomas). CASE DESCRIPTION We surgically treated two patients with a nonfunctional cord-like structure (C-LS) that was continuous from the cord and extended to the dural cul-de-sac, and ran parallel to the terminal lipoma. In both cases, untethering surgery was performed by resecting the C-LS with lipoma as a column, under intraoperative neurophysiological monitoring. Histopathological examination confirmed that the central canal-like ependyma-lined lumen with surrounding neuroglial and fibrocollagenous tissues, which is the central histopathological feature of an RMC, was located on the unilateral side of the resected column, while the fibroadipose tissues of the lipoma were located on the contralateral side. CONCLUSION Our findings support the idea proposed by Pang et al. that entities such as RMC and terminal lipomas are members of a continuum of regression failure occurring during late secondary neurulation, and the coexistence of RMC and terminal lipoma is not a surprising finding. Therefore, it may be difficult in clinical practice to make a distinct diagnosis between these two entities.
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Affiliation(s)
- Ai Kurogi
- Department of Neurosurgery, Fukuoka Children’s Hospital, Saga, Japan
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children’s Hospital, Saga, Japan
| | - Takato Morioka
- Department of Neurosurgery, Harasanshin Hospital, Saga, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Kyushu University, Saga, Japan
| | | | - Kyoko Kudo
- Department of Dermatology, Fukuoka Children’s Hospital, Saga, Japan
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35
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Lalgudi Srinivasan H, Valdes-Barrera P, Agur A, Soleman J, Ekstein M, Korn A, Vendrov I, Roth J, Constantini S. Filum terminale lipomas-the role of intraoperative neuromonitoring. Childs Nerv Syst 2021; 37:931-939. [PMID: 32767104 DOI: 10.1007/s00381-020-04856-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Filum terminale lipomas (FTL) represent a sub-type of spinal lipomas, where there is fatty infiltration of the filum. It becomes a surgical entity when it manifests as clinical or radiological tethered cord syndrome. Intraoperative neuromonitoring (IONM) has been suggested as a valuable tool in children for tethered cord surgeries. FTL is distinct and cannot be compared with complex tethered cord syndrome (TCS). Untethering an FTL is a relatively straightforward microsurgical exercise, usually based on anatomical findings. Neurological morbidity in FTL untethering is extremely low. The necessity of IONM in FTL has not been evaluated. The objective of this study was to identify the role of IONM in untethering an FTL METHODS: Available electronic data and case files were interrogated to identify children (0-18 years) who underwent an untethering of FTL between 2008 and 2019. We had a shift in our policy and tried to use IONM as often as possible in all tethered cord surgery from 2014. All children were categorised under 'IONM implemented' or 'no IONM' group. Outcomes analysed were as follows: (1) Clinical status on short-term and long-term follow-up, (2) alteration of surgical course by IONM and (3) complications specifically associated with IONM RESULTS: Among 80 children included in this study, IONM was implemented in 37 children and 43 children underwent untethering without IONM. 32.5% of children were 'syndromic'. Seventy-five percent of children were under age 3 years during surgery. Both groups (No IONM vs. IONM implemented) were well matched in most variables. Majority of 'no IONM' surgeries were performed prior to 2014. There was no neurological morbidity in the entire cohort. Mean duration of follow-up was 49.10 (± 33.67) months. Short-term and long-term clinical status remained stable in both cohorts. In 16 children, the filum was stimulated. Based on our protocol, majority had a negative response. One child showed a positive response, contradicted by thorough microscopic inspection. Despite a positive response, the filum was untethered. IONM was not associated with any complication in this study. CONCLUSION FTL untethering is an inherently low-risk microsurgery in experienced hands with rarely reported neurological morbidity. IONM may not be required for all FTL and may be used more judiciously.
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Affiliation(s)
- Harishchandra Lalgudi Srinivasan
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Pablo Valdes-Barrera
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Agur
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Jehuda Soleman
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel.,Department of Neurosurgery, Division of Paediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Margaret Ekstein
- Division of Anaesthesiology, Intensive Care, and Pain Medicine, Tel-Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Akiva Korn
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel.,Intraoperative Neurophysiology Service, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Irina Vendrov
- Intraoperative Neurophysiology Service, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel
| | - Jonathan Roth
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Paediatric Neurosurgery Department, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel.
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Murakami N, Morioka T, Suzuki SO, Mukae N, Shimogawa T, Matsuo Y, Sasaguri T, Mizoguchi M. Clinicopathological findings of limited dorsal myeloschisis associated with spinal lipoma of dorsal-type. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Expression Patterns of Hypoxia-Inducible Factors, Proinflammatory, and Neuroprotective Cytokines in Neuroepithelial Tissues of Lumbar Spinal Lipomas-A Pilot Study. World Neurosurg 2020; 141:e633-e644. [PMID: 32522652 DOI: 10.1016/j.wneu.2020.05.256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Lumbosacral lipomas (LSLs), one form of closed spinal dysraphism, are congenital disorders of the terminal spinal cord (SC). Delayed neurologic deterioration often occurs in the subsequent developmental course of the patient. Identifying the cellular and molecular factors underlying the progressive damage to neural structures is a prerequisite for developing treatment strategies for LSLs. METHODS Nine LSL specimens obtained from the SC/lipoma interface during surgical resection were examined. Normal SC tissue served as a control. Clinical characteristics were obtained, and spinal magnetic resonance imaging was re-evaluated. Cellular marker profiles were established. Immunoreactivity (IR) of hypoxia-inducible factor 1α (HIF-1α/-2α), erythropoietin (Epo)/erythropoietin receptor (EpoR), interleukin-1β (IL-1β)/IL-1R1, and tumor necrosis factor α/tumor necrosis factor receptor type 1 were analyzed qualitatively and semiquantitatively by densitometry. Colabeling with cellular markers was determined by multifluorescence labeling. Cytokines were further analyzed by real-time reverse transcription polymerase chain reaction. RESULTS LSL specimens showed significant gliosis. HIF-1α/HIF-2α-IR and Epo/Epo-IR were found at significantly higher levels in the LSL specimens, as were IL-1β-/IL-1β receptor type 1 (IL1-R1) and tumor necrosis factor α/tumor necrosis factor receptor type 1 (P < 0.001), than were the controls. At the messenger RNA level, cytokines appeared partially induced. Double immunofluorescence labeling confirmed the costaining of these factors with inflammatory and glial markers. CONCLUSIONS The expression of hypoxia-related and inflammatory mediators was shown for the first time in LSL specimens. These factors might play a role in multifactorial secondary lesion cascades underlying further damage to the neural placode in closed dysraphism.
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Rhodes RH. Congenital Spinal Lipomatous Malformations. Part 1. Spinal Lipomas, Lipomyeloceles, and Lipomyelomeningoceles. Fetal Pediatr Pathol 2020; 39:194-245. [PMID: 31342816 DOI: 10.1080/15513815.2019.1641859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Lumbosacral spinal lipomas and lipomyeloceles are usually identified in early childhood. Terminology, histopathology, and diagnosis for these malformations can be confusing. Materials and Methods: This is a PubMed review with comparison of embryology, gross, and histopathology, and reporting requisites for these and related closed spinal malformations. Results: The spinal lipoma group (congenital spinal lipomatous malformations) includes subcutaneous, transdural, intradural, and noncontiguous malformations stretching through the entire lower spinal region. This lipomyelocele trajectory overlaps the embryonic tail's caudal eminence. Histopathologically, the lipomyelocele spectrum is a heterogeneous, stereotypical set of findings encountered from dermis to spinal cord. Diagnosis requires detailed correlation of images, intraoperative inspection, and histopathology. Conclusions: Appropriate terminology and clinicopathologic correlation to arrive at a diagnosis is a critical activity shared by pathologist and clinician. Prognostic and management differences depend on specific diagnoses. Familial and genetic influences play little if any role in patient management in closed spinal malformations.
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Affiliation(s)
- Roy H Rhodes
- LSUHSC, Pathology, New Orleans, Louisiana, USA.,Rutgers Robert Wood Johnson Medical School, Pathology, New Brunswick, New Jersey, USA
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Batista Cezar-Junior A, Faquini IV, Frank K, Euripedes Almondes S Lemos L, de Carvalho EV, Almeida NS, Azevedo-Filho HRC. Limited dorsal myeloschisis with a contiguous stalk to human tail-like cutaneous appendage, associated with a lipoma of conus medullaris: A case report. Int J Surg Case Rep 2020; 71:303-306. [PMID: 32480343 PMCID: PMC7264008 DOI: 10.1016/j.ijscr.2020.05.021] [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: 04/19/2020] [Revised: 05/03/2020] [Accepted: 05/03/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Limited dorsal myeloschisis (LDM) is a recently described pathological entity, characterized by a defect of the closed focal neural tube and a fibroneural pedicle connecting the cutaneous lesion to the spinal cord. PRESENTATION OF THE CASE This case describes a 9-month-old child with a human tail and an underlying spinal dysraphism. This was represented by LDM stalk associated with a medullary lipoma, in connection with the dorsal cutaneous appendage. We also report the therapeutic proposal for this case and its clinical outcome. DISCUSSION LDM is a distinctive clinicopathological presentation of a spinal dysraphism, associated with numerous anomalies, such as lipomyelomeningocele, tethered cord, lipoma, congenital heart disease and teratoma. In this case, surgical treatment for LDM consists of surgical resection of the appendage, untethering of the spinal cord and resection of conus medullaris lipoma in the same procedure. CONCLUSION In this case report, we share the experience of a referral service in pediatric neurosurgery regarding clinical and radiological diagnosis, and the successful treatment of this rare type of congenital malformation. Therefore, clinicians should be aware of possible morphological variations of the skin lesion associated with LDM.
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Affiliation(s)
| | - Igor Vilela Faquini
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, Brazil.
| | - Kauê Frank
- Neurosurgery Department of the Hospital da Restauração Gov. Paulo Guerra, Recife, Brazil.
| | | | | | - Nivaldo S Almeida
- Neurosurgery Department of the Hospital da Restauração Gov. Paulo Guerra, Recife, Brazil.
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Tominey S, Kaliaperumal C, Gallo P. External validation of a new classification of spinal lipomas based on embryonic stage. J Neurosurg Pediatr 2020; 25:394-401. [PMID: 31978883 DOI: 10.3171/2019.11.peds19575] [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: 09/28/2019] [Accepted: 11/15/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Contention exists regarding appropriate classification and management of spinal lipomas (SLs). Given the heterogeneity of SLs, omissions and overlap between surgically incomparable groups exist in conventional classification systems. The new classification of spinal lipoma (NCSL) recently proposed by Morota et al. delineates morphology by embryological pathogenesis and the resultant operative difficulty. Here, the authors aimed to validate the NCSL by applying it to patients who had been operated on at their institution. METHODS All children who had undergone resection for SL between 2014 and 2018 were included in this analysis. MRI studies were independently reviewed and classified by three adjudicators. Baseline characteristics, inter-adjudicator agreement, coexisting anomalies and/or malformations, and postoperative outcomes and complications were analyzed. RESULTS Thirty-six patients underwent surgical untethering for SL: NCSL type 1 in 5 patients (14%), type 2 in 14 patients (39%), type 3 in 4 patients (11%), and type 4 in 13 patients (36%). All classification was agreed on first assignment by the adjudicators. Radical or near-radical resection, which was attempted in all patients, was always possible in those with type 1 and 4 SL, but never in those with type 2 and 3 SL. Neurological stabilization and/or improvement were observed in all patients at the last follow-up. CONCLUSIONS The NCSL was found to be a logical and reproducible system to apply in this SL population. All cases were successfully classified with a high degree of inter-assessor agreement. Widespread establishment of a commonly adopted and clinically useful classification system will enable clinicians to improve patient selection as well as discussion with patient representatives during the decision-making process.
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Affiliation(s)
| | | | - Pasquale Gallo
- 2Department of Pediatric Neurosurgery, Royal Hospital for Sick Children, Edinburgh, United Kingdom
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Spinal intramedullary dermoid cyst associated with filar lipoma: A case report and literature review. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2019. [DOI: 10.1016/j.inat.2019.100546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Marek T, Mahan MA, Carter JM, Amrami KK, Atkinson JL, Spinner RJ. Can Lipomatosis of the Nerve Occur or Extend Intradurally? World Neurosurg 2019; 129:e555-e560. [DOI: 10.1016/j.wneu.2019.05.213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/24/2022]
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Morota N. Intraoperative neurophysiological monitoring of the bulbocavernosus reflex during surgery for conus spinal lipoma: what are the warning criteria? J Neurosurg Pediatr 2019; 23:639-647. [PMID: 30797211 DOI: 10.3171/2018.12.peds18535] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 12/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite the surge in the intraoperative use of the bulbocavernosus reflex (BCR) during lumbosacral surgeries, there are as yet no widely accepted BCR warning criteria for use with intraoperative neurophysiological monitoring (IONM). The author's aim was to find clinically acceptable warning criteria for use in IONM of the BCR. METHODS Records of IONM of the BCR in 164 operations in 163 patients (median age 5 months) with a conus spinal lipoma who underwent surgery between August 2002 and May 2016 were retrospectively analyzed. The outcomes of IONM of the BCR were grouped by the residual amplitude at the end of surgery: group 1, ≥ 50%; group 2, 25%-50% (including the lower bound, but not the upper); and group 3, < 25%. Cases in which the BCR was lost were separately assessed as a subgroup of group 3. The postoperative urinary complication rate was used to verify the warning criteria zones. RESULTS The BCR could be monitored in 149 surgeries (90.9%). There were 118 surgeries (79.2%) in group 1, 18 (12.1%) in group 2, and 13 (8.7%) in group 3. Two surgeries (11.1%) in group 2 and 6 (46.2%) in group 3 resulted in urinary complications. In the group 3 subgroup (lost BCR), all 5 surgeries resulted in urinary complications. The cutoff value of the BCR amplitude reduction was placed between groups 1 and 2 (zone 1: cutoff 50%), groups 2 and 3 (zone 2: cutoff 25%), and group 3 and its subgroup (zone 3: cutoff zero, present or lost). In zone 1, the positive predictive value (PPV) was 25.8% and the negative predictive value (NPV) was 100%. In zone 2, the PPV was 53.8% and the NPV 98.5%. In zone 3, the PPV was 100% and the NPV 97.9%. The PPV was highest in zone 3. The NPV was highest in zone 1, but its PPV was low (25.8%). CONCLUSIONS The "lost or remained" criterion of BCR amplitude (zone 3: cutoff zero) can be used as a predictor of postoperative urinary function. As a warning criterion, the cutoff value of the BCR amplitude reduction at 75% (zone 2) may be used. This preliminary clinical report on the warning criteria for the BCR may contribute to improving the safety of surgery for conus spinal lipoma.
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Impact of the associated anorectal malformation on the outcome of spinal dysraphism after untethering surgery. Pediatr Surg Int 2019; 35:227-231. [PMID: 30390136 DOI: 10.1007/s00383-018-4400-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To analyze the outcome after untethering surgery in patients with spinal dysraphism (SD), with or without associated anorectal malformation (ARM). METHODS Patients operated on for SD, with (Group A) or without (Group B) associated ARM (1999-2015), were included. The post-operative outcome was analyzed in the two groups in terms of improving of clinical symptoms (neuro-motor deficits, bladder dysfunction, bowel dysfunction) and of instrumental examinations (urodynamics, bladder ultrasound, neurophysiology). Fisher's exact test and χ2 test were used as appropriate; p < 0.05 was considered statistically significant. MAIN RESULTS Ten patients in Group A and 24 in Group B were consecutively treated. One patient was lost at follow up. Six patients (25%) in Group B underwent prophylactic surgery. The analysis of the pre-operative symptoms in the two groups showed that a significantly higher number of patients in group A needed bowel management and presented with neuro-motor deficits, compared to group B (p = 0.0035 and p = 0.04, respectively). Group A showed a significant post-operative neuro-motor improvement as compared to group B (p = 0.002). CONCLUSIONS Based on our results, untethering seems to be effective in neuro-motor symptoms in selected patients with ARM. In ARM patients, untethering surgery does not seem to benefit intestinal and urinary symptoms. The presence of the associated ARM does not seem to impact the medium-term outcome of patients operated for SD.
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Morioka T, Suzuki SO, Murakami N, Mukae N, Shimogawa T, Haruyama H, Kira R, Iihara K. Surgical histopathology of limited dorsal myeloschisis with flat skin lesion. Childs Nerv Syst 2019; 35:119-128. [PMID: 29934704 DOI: 10.1007/s00381-018-3870-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/15/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Limited dorsal myeloschisis (LDM) is characterized by two invariable features: a focal closed neural tube defect and a fibroneural stalk linking the skin lesion to the underlying spinal cord. Although detailed histopathological findings of the LDM stalk were originally described by Pang et al., the precise relationship between the histopathological findings and clinical manifestations including intraoperative findings has not been fully determined. METHODS We retrospectively analyzed the histopathological findings of the almost entire stalk and their relevance to the clinical manifestations in six Japanese LDM patients with flat skin lesions. RESULTS Glial fibrillary acidic protein (GFAP)-immunopositive neuroglial tissues were observed in three of the six patients. Unlike neuroglial tissues, peripheral nerve fibers were observed in every stalk. In four patients, dermal melanocytosis, "Mongolian spot," was seen surrounding the cigarette-burn lesion. In three of these four patients, numerous melanocytes were distributed linearly along the long axis of the LDM stalk, which might represent migration of melanocytes from trunk neural crest cells during formation of the LDM stalk. CONCLUSION Immunopositivity for GFAP in the LDM stalk was observed in as few as 50% of our patients, despite the relatively extensive histopathological examination. We confirm that the clinical diagnosis of LDM should be made based on comprehensive histopathological examination as well as clinical manifestations. The profuse network of peripheral nerve fibers in every stalk and the high incidence of melanocyte accumulation associated with dermal melanocytosis might assist the histopathological diagnosis of LDM.
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Affiliation(s)
- Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan.
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Nobutaka Mukae
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takafumi Shimogawa
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan.,Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hironori Haruyama
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Hiraoka A, Morioka T, Murakami N, Suzuki SO, Mizoguchi M. Limited dorsal myeloschisis with no extradural stalk linking to a flat skin lesion: a case report. Childs Nerv Syst 2018; 34:2497-2501. [PMID: 30083799 DOI: 10.1007/s00381-018-3938-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/27/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Limited dorsal myeloschisis (LDM) is characterized by a fibroneural stalk linking the skin lesion to the underlying spinal cord. CASE PRESENTATION : A 7-month-old girl with a lumbosacral "cigarette-burn" flat skin lesion underwent untethering surgery. The intradural tethering stalk appeared to originate at the dural wall and join the cord with no extradural stalk linking to the skin lesion. Histological examination of the intradural stalk revealed glial fibrillary acidic protein-immunopositive neuroglial tissues in the fibrocollagenous band, which is the central histopathological feature of an LDM stalk. CONCLUSION It is conceivable that the LDM stalk in our patient was originally linked to the skin lesion and subsequently regressed and was replaced by mature adipose tissue. We should be mindful of possible variations in the morphological features of LDM.
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Affiliation(s)
- Akiko Hiraoka
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takato Morioka
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan.
| | - Nobuya Murakami
- Department of Neurosurgery, Fukuoka Children's Hospital, 5-1-1 Kashii-teriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Satoshi O Suzuki
- Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahiro Mizoguchi
- Department of Neurosurgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
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Gour SSK, Agrawal M, Borkar SA. Letter to the Editor. Laminotomy outcomes in pediatric patients. J Neurosurg Pediatr 2018; 22:595-597. [PMID: 30117792 DOI: 10.3171/2018.5.peds18225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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48
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Enlargement of sacral subcutaneous meningocele associated with retained medullary cord. Childs Nerv Syst 2018; 34:1785-1790. [PMID: 29704125 DOI: 10.1007/s00381-018-3812-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND A retained medullary cord (RMC) is a rare closed spinal dysraphism with a robust elongated neural structure continuous from the conus and extending to the dural cul-de-sac. Four cases of RMC extending down to the base of an associated subcutaneous meningocele at the sacral level have been reported. CLINICAL PRESENTATION We report an additional case of RMC, in whom serial MRI examination revealed an enlargement of the meningocele associated with RMC over a 3-month period between 8 and 11 months of age, when he began to stand. At the age of 12 months, untethering of the cord was performed. Histologically, the presence of ependyma-lined central canals in the dense neuroglial cores was noted in all cord-like structures in the intradural and intrameningocele sacs and at the attachment to the meningocele. CONCLUSION It is conceivable that the hydrodynamic pressure with standing position and the check valve phenomenon were involved in meningocele enlargement. We should be mindful of these potential morphological changes.
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Retained medullary cord extending to a sacral subcutaneous meningocele. Childs Nerv Syst 2018; 34:527-533. [PMID: 29101613 DOI: 10.1007/s00381-017-3644-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND A retained medullary cord (RMC) is a rare closed spinal dysraphism with a robust elongated neural structure continuous from the conus and extending to the dural cul-de-sac. One case extending down to the base of a subcutaneous meningocele at the sacral level has been reported. CLINICAL PRESENTATION We report on three cases of closed spinal dysraphism, in which a spinal cord-like tethering structure extended out from the dural cul-de-sac and terminated at a skin-covered meningocele sac in the sacrococcygeal region, which was well delineated in curvilinear coronal reconstructed images of 3D-heavily T2-weighted images (3D-hT2WI). Intraoperative neurophysiology revealed the spinal cord-like tethering structure was nonfunctional, and histopathology showed that it consisted of central nervous system tissue, consistent with RMC. The tethering structure histologically contained a glioneuronal core with an ependymal-like lumen and smooth muscle, which may indicate developmental failure during secondary neurulation. CONCLUSIONS When the RMC extending to a meningocele is demonstrated with the detailed magnet resonance imaging including 3D-hT2WI, decision to cut the cord-like structure for untethering of the nervous tissue should be made under careful intraoperative neurophysiological monitoring.
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Abstract
This overview of mesenchymal tumors presenting in the skin and/or subcutis in children brings together the range of neoplasms and hamartomas which are seen in this age-group. It is not surprising from the perspective of the pediatric or general surgical pathologist that vascular anomalies, including true neoplasms and vascular malformations, are the common phenotypic category. Since there is considerable morphologic overlap among these lesions, clinicopathologic correlation may be more important than for many of the other mesenchymal tumors. The skin and subcutis are the most common sites of clinical presentation for the infantile myofibroma which is the most common of fibrous mesenchymal tumors in children. Several of the other mesenchymal tumors are more common adults-like dermatofibrosarcoma protuberans, but nonetheless have an important presence in children, even as a congenital neoplasm. A lipomatous tumor in a young child should be considered as a possible manifestation of an overgrowth syndrome.
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Affiliation(s)
- Louis P Dehner
- 1 Lauren V. Ackerman Laboratory of Surgical Pathology, St. Louis Children's Hospital, Washington University Medical Center, St. Louis, Missouri.,2 Dermatopathology Center and Division of Dermatology, Washington University Medical Center, St. Louis, Missouri
| | - Alejandro A Gru
- 3 Department of Pathology, University of Virginia, Charlottesville, Virginia.,4 Department of Dermatology, University of Virginia, Charlottesville, Virginia
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