The nature of congenital posterior cervical or cervicothoracic midline cutaneous mass lesions. Report of eight cases

Prenatal Diagnosis and Outcomes of Cervical Meningocele and Myelomeningocele

Prenatal diagnosis of myelomeningocele remains challenging for obstetricians, ultrasonographers, and radiologists, although the increased maternal serum alpha-fetoprotein level aids in the confirmative diagnosis. Fetal cervical myelomeningocele and meningocele are very rare and unique types of myelomeningocele. Prenatal diagnosis of cervical myelomeningocele and meningocele should include the differential diagnosis and association of many intracranial and spino-skeletal pathogenetic variants and genetic diseases, including subependymal nodular heterotopia and Klippel-Feil syndrome. In this report, a comprehensive review of fetal cervical myelomeningocele with its prenatal diagnosis and long-term outcomes is presented.

Cervical Myelocystocele: A One-in-50,000 Congenital Abnormality of the Spinal Cord

Neural tube defects are a group of birth defects that affect the development of the spinal cord and brain. Myelomeningocele is a type of neural tube defect that results in the protrusion of the spinal cord and meninges through a defect in the vertebral column. While myelomeningocele is a relatively rare condition, cervical myelomeningocele is extremely uncommon. The condition can lead to various neurological problems and atrophies and is typically diagnosed in the first trimester of pregnancy using an ultrasound examination. Surgical intervention is typically recommended to repair the affected vertebral column. In this report, we describe the case of a four-month-old baby boy who was diagnosed with a cervical myelocystocele and successfully treated surgically. The patient had an excellent postoperative status, and this case highlights the importance of early diagnosis and intervention in the management of this rare condition.

Focal Spinal Nondisjunctional Disorders: Including a Discussion on the Embryogenesis of Cranial Focal Nondisjunctional Lesions

The publication of a comprehensive report on limited dorsal myeloschisis by the senior author (DP) in 2010 has brought full attention to the concept of limited myeloschisis that he first formulated in 1992 and ignited interests in the whole spectrum of focal spinal nondisjunctional disorders. Now that focal nondisjunctional disorders have become well known, new clinical reports on these conditions or relevant subjects are frequently seen. Here we present an updated review on the full spectrum of focal spinal nondisjunctional disorders and extend the scope to include a discussion on the embryogenesis of cranial focal nondisjunctional malformations.

Lumbosacral non-terminal myelocystocele associated with teratoma: case report and review of literature

Non-terminal myelocystoceles are commonly found in the cervical or thoracic spinal region. Their sac can rarely be associated with tumor. A rare case of an infant with a lumbosacral non-terminal myelocystocele and accompanying mature teratoma is reported in whom the tumor was attached to the placode not as a part of the sac.

Focal Spinal Nondisjunction in Primary Neurulation : Limited Dorsal Myeloschisis and Congenital Spinal Dermal Sinus Tract

Spinal dysraphic lesions due to focal nondisjunction in primary neurulation are commonly encountered in paediatric neurosurgery, but the “fog-of-war” on these conditions was only gradually dispersed in the past 10 years by the works of the groups led by the senior author and Prof. Kyu-Chang Wang. It is now clear that limited dorsal myeloschisis and congenital spinal dermal sinus tract are conditions at the two ends of a spectrum; and mixed lesions of them with various configurations exist. This review article summarizes the current understanding of these conditions’ embryogenetic mechanisms, pathological anatomy and clinical manifestations, and their management strategy and surgical techniques.

Congenital Spinal Lipomatous Malformations. Part 2. Differentiation from Selected Closed Spinal Malformations

BACKGROUND

Congenital spinal lipomatous malformations (spinal lipomas, lipomyeloceles, and lipomyelomeningoceles) are closed neural tube defects over the lower back. Differentiation from some other closed neural tube defects in this region can be problematic for pathologists.

MATERIALS AND METHODS

This review is based on PubMed searches of the embryology, gross and histopathologic findings, and laboratory reporting requisites for retained medullary spinal cords, coccygeal medullary vestiges and cysts, myelocystoceles, true human vestigial tails, and pseudotails for comparison with congenital spinal lipomatous malformations.

RESULTS

Embryology, imaging, gross and histopathology of these closed neural tube lesions have different but overlapping features compared to congenital spinal lipomatous malformations, requiring context for diagnosis.

CONCLUSION

The lipomyelocele spectrum and to some degree all of the malformations discussed, even though they may not share gross appearance, anatomic site, surgical approach, or prognosis, require clinical and histopathologic correlation for final diagnosis.

Cervical myelomeningocele with CSF leakage: a case-based review

BACKGROUND

The cystic spinal dysraphism of the cervical and upper thoracic region (CDCT) accounts for only 3.9 to 8% of spina bifida cystica lesions. The presence of external cerebrospinal fluid (CSF) leakage is infrequent and very few authors have reported about surgical complications.

CASE REPORT

We present the case of a new born diagnosed of CDCT C1-C3 with a stalk of fibrovascular tissue, CSF leakage, hydrocephalus, and type Chiari II malformation, discuss about the chosen surgical technique and the associated complications, and make a review of the literature focusing on the main aspects of CDCT.

CONCLUSIONS

The CDCT with a stalk of neuroglial and/or fibrovascular tissue originates from the dorsal surface of the spinal cord and penetrates into a cervical cystic sac. The presence of CSF leakage, hydrocephalus, and/or type Chiari II malformation can influence to decide the most appropriate surgical technique.

Limited dorsal myeloschisis associated with dermoid elements

INTRODUCTION

Limited dorsal myeloschisis (LDM) originates from undisjointed neural and cutaneous ectoderms during primary neurulation. Its hallmark is a fibroneural stalk causing tethering on the dorsal spinal cord rostral to the conus. Its treatment is a relatively straightforward resection of the LDM stalk from the spinal cord.

METHODS AND RESULTS

On reviewing our series of 75 cases of LDMs, we found that the majority of LDM stalks have only a glioneuronal core within a fibrous stroma, but a small number have been found to have elements of dermoid cyst or a complete dermal sinus tract either contiguous with the fibroneural stalk or incorporated within its glial matrix, not surprising considering the original continuum of cutaneous and neural ectoderm in LDMs' embryogenesis. The dermoid element can be microscopic and escape casual observation, but could grow to large intradural dermoid cysts if part of the dermoid invested LDM stalk is left inside the dura.

CONCLUSIONS

We present our series of LDMs associated with dermoid elements and recommend excising the entire length of the intradural LDM stalk from its dural entry point to its merge point with the spinal cord during the initial treatment to avoid secondary deterioration and additional surgery.

Cervicothoracic cystic dysraphism

Cystic dysraphism of the cervical and upper thoracic spine is very rare. It differs from the much more common lumbosacral dysraphism in appearance and structure, and usually portends a better prognosis due to lack of functional neurological tissue in the dysraphic sac and absent or less severe intracranial anomalies. There is ambiguity in the literature regarding terminology because of the paucity of cases. We present cases of the most common type of cervicothoracic cystic dysraphism and emphasize differences from lumbosacral myelomeningocele. Patient outcome depends on the presence of associated anomalies and whether complete surgical resection is performed. Imaging plays a critical role in surgical planning, screening the central nervous system for additional anomalies, and in the postoperative setting for evaluation of retethering.

Asymptomatic posterior cervical myelomeningocele with tethered cord in an adolescent: a rare form of spinal dysraphism with rare presentation

Unlike lumbar spinal dysraphism, cervical spinal dysraphism with or without tethered cord are rare lesions. These lesions are generally asymptomatic at birth, but with progression of time symptoms develop. These may be associated with various other anomalies. Not much have been reported in literature about cervical myelomeningocele (MMC) in adults or adolescents. We report a case of a 17 years old adolescent boy with cervical myelomeningocele with tethered cervical cord, who was completely intact neurologically even at this age and was without any associated anomaly. He came to us only for cosmetic reasons. The tethering band, which was evident on imaging was confirmed intra-operatively.

True Cervicothoracic Meningocele: A Rare and Benign Condition

Cervical meningoceles are rare spinal dysraphism, accounting for approximately 7% of all cystic spinal dysraphism. In spite of the rarity, the clinical course is most of the times benign. The surgical treatment includes resection of the lesion and untethering, when presented. We present a 14-day-old female child with true meningoceles who underwent to surgical excision and dura-mater repair. Retrospect analysis of the literature concerning true cervical meningocele is performed. By reporting this illustrative case, we focus on its classification and its differentiation from other types of cervical spinal dysraphism, such as myelocystocele and myelomeningocele. Although its course is benign, it is mandatory a continuum follow up with periodic magnetic resonance imaging of spinal cord, since late neurological deterioration has been described.

Congenital Brain and Spinal Cord Malformations and Their Associated Cutaneous Markers

The brain, spinal cord, and skin are all derived from the embryonic ectoderm; this common derivation leads to a high association between central nervous system dysraphic malformations and abnormalities of the overlying skin. A myelomeningocele is an obvious open malformation, the identification of which is not usually difficult. However, the relationship between congenital spinal cord malformations and other cutaneous malformations, such as dimples, vascular anomalies (including infantile hemangiomata and other vascular malformations), congenital pigmented nevi or other hamartomata, or midline hairy patches may be less obvious but no less important. Pediatricians should be aware of these associations, recognize the cutaneous markers associated with congenital central nervous system malformations, and refer children with such markers to the appropriate specialist in a timely fashion for further evaluation and treatment.

A rare case of thoracic myelocystocele associated with type 1 split cord malformation with low lying tethered cord, dorsal syrinx and sacral agenesis: Pentad finding

Myelocystocele is a rare form of spinal dysraphism. Thoracic myelocystocele is still rarer. The occurrence of thoracic myelocystocele associated with type-1 split cord malformation, low lying tethered cord, dorsal syrinx and spina bifida is extremely rare. Clinical presentation of such a rare case and an early surgical management is discussed briefly.

Cervicothoracic nonterminal myelocystocele with mature teratoma

Nonterminal myelocystocele is a rare type of spinal dysraphism characterized by a closed defect with an underlying CSF-filled cyst, either contiguous with the central spinal canal or attached to the spinal cord by a fibrovascular stalk. The authors report the unusual case of a neonate with a prenatal diagnosis of cervicothoracic nonterminal myelocystocele who underwent postnatal surgical untethering of the lesion. Pathological analysis of the excised lesion revealed neuroglial tissue with an ependymal lining associated with a mature teratoma. Three months after surgery, the patient has normal lower-extremity sensorimotor function and no evidence of bowel or bladder dysfunction. To the best of the authors' knowledge, this is the first report of a patient with a nonterminal myelocystocele found to have an associated mature teratoma.

Limited dorsal myeloschisis: a not-so-rare form of primary neurulation defect

PURPOSE

Limited dorsal myeloschisis (LDM) is a distinctive form of spinal dysraphism characterized by two constant features: a focal "closed" midline skin defect and a fibroneural stalk that links the skin lesion to the underlying cord. The embryogenesis is hypothesized to be incomplete disjunction between cutaneous and neural ectoderms, thus preventing complete midline skin closure and allowing persistence of a physical link (fibroneural stalk) between the disjunction site and the dorsal neural tube.

OBJECTIVE

We utilize the experience gained from the management of 63 patients with LDM to illustrate these features.

METHODS

All patients were studied with MRI or CT myelogram, operated on, and followed for a mean of 9.4 years.

RESULTS

There were 11 cervical, 16 thoracic, 8 thoracolumbar, and 28 lumbar lesions. Two main types of skin lesion were: saccular (26 patients; consisting of a skin base cerebrospinal fluid sac topped with squamous epithelial dome or a thin membranous sac) and nonsaccular (37 patients; with a flat or sunken squamous epithelial crater or pit). The internal structure of a saccular LDM could be a basal neural nodule, a stalk that inserts on the dome, or a segmental myelocystocoele. In nonsaccular LDMs, the fibroneural stalk has variable thickness and complexity. All fibroneural stalks contain glioneuronal tissues accompanied by variable quantities of nerves and mesodermal derivatives. In all LDMs, the fibroneural stalk was tethering the cord. Twenty-nine patients had neurological deficits. There was a positive correlation between neurological grade and age suggesting progression with chronicity. Treatment consisted of detaching the stalk from the cord. Most patients improved or remained stable. LDMs were associated with three other dysraphic malformations in more than coincidental frequencies: six LDMs were contiguous with dorsal lipomas, four LDMs shared the same tract or traveled in parallel with a dermal sinus tract, and seven LDMs were related to a split cord malformation. The embryogenetic implications of these associations are discussed.

CONCLUSION

LDM is a distinctive clinicopathological entity and a tethering lesion with characteristic external and internal features. We propose a new classification incorporating both saccular and flat lesions.

Poland syndrome with extracorporeal intercostal liver herniation and thoracic myelomeningocele

Poland syndrome is characterized by hypoplastic unilateral chest wall structures. These chest wall deformities may be associated with upper extremity anomalies. The association of Poland syndrome with either intercostal liver herniation or a spinocerebral deformity has been described, but there is no report of both findings encountered simultaneously. This is the first report of a newborn child with Poland syndrome associated with an intercostal liver segment herniation and thoracic myelomeningocele with features of an Arnold-Chiari II cerebral malformation.

Anterior cervical myelomeningocele: a rare malformation of the spinal cord

Cervical myelomeningocele (MMC) is an uncommon congenital malformation of the spinal cord and accounts for a small proportion of neural tube defects. These lesions mostly occur in the dorsal part of the body. Only a single case of an anterior cervical MMC has been previously reported. The authors report a second case of anterior cervical MMC diagnosed when the patient began to experience symptoms of bilateral hand weakness in adulthood. In this patient, MR imaging of the cervical spine showed an anterior cervical MMC at the C6-7 level with hydrocephalus, thinning of the genu and trunk of the corpus callosum, maldevelopment of the cerebellar tonsils, and expansion of the fourth ventricle, posterior cranial fossa, and subarachnoid space. A CT scan and a 3D CT reconstruction of the cervical spine clearly demonstrated contiguous fusions of multiple lower-cervical vertebrae and neural arches, which was consistent with Type III Klippel-Feil syndrome. The patient was advised to undergo operative treatment to prevent the progression of her neurological deficit. However, after being notified of the potential neurological risks, the patient declined surgery and opted for conservative treatment with a hard neck collar. At 4 months' follow-up, the patient's neurological deficit remains stable with the MMC left untreated. The authors presume that the possible pathogenesis of anterior cervical MMC may greatly differ from that of posterior lesions. This lesion could also be associated with multiple other spinal abnormalities, which highlights the importance of comprehensive preoperative radiological examinations.

Cervical myelocystocele: Case report and review of literature

Dysraphisms involving cervical region are very rare and there are very few series describing their follow-up in literature. Here, we report a 6-year-old boy who underwent postnatal “cosmetic” repair of posterior cervical cystic lesion and presented to us with a large recurrence with syringohydromyelia and tethering. Tethered cord should be suspected in the presence of meningocele and intact neurology. Treatment protocols of such complicated cervical spinal dysraphisms should include intradural exploration and detethering, with an aim to prevent neurological deterioration in future.

Limited dorsal myeloschisis: a distinctive clinicopathological entity

BACKGROUND

Limited dorsal myeloschisis (LDM) is a distinctive form of spinal dysraphism characterized by 2 constant features: a focal "closed" midline defect and a fibroneural stalk that links the skin lesion to the underlying cord. The embryogenesis is hypothesized to be incomplete disjunction between cutaneous and neural ectoderms, thus preventing complete midline skin closure and allowing persistence of a physical link (fibroneural stalk) between the disjunction site and the dorsal neural tube.

OBJECTIVE

To illustrate these features in 51 LDM patients.

METHODS

All patients were studied with magnetic resonance imaging or computed tomography myelography, operated on, and followed for a mean of 7.4 years.

RESULTS

There were 10 cervical, 13 thoracic, 6 thoracolumbar and 22 lumbar lesions. Two main types of skin lesion were saccular (21 patients), consisting of a skin-base cerebrospinal fluid sac topped with a squamous epithelial dome, and nonsaccular (30 patients), with a flat or sunken squamous epithelial crater or pit. The internal structure of a saccular LDM could be a basal neural nodule, a stalk that inserts on the dome, or a segmental myelocystocele. In nonsaccular LDMs, the fibroneural stalk has variable thickness and complexity. In all LDMs, the fibroneural stalk was tethering the cord. Twenty-nine patients had neurological deficits. There was a positive correlation between neurological grade and age, suggesting progression with chronicity. Treatment consisted of detaching the stalk from the cord. Most patients improved or remained stable.

CONCLUSION

LDM is a distinctive clinicopathological entity and a tethering lesion with characteristic external and internal features. We propose a new classification incorporating both saccular and flat lesions.

Characteristics and surgery of cervical myelomeningocele

OBJECTIVE

Cervical myelomeningocele (CMMC) is a rare entity in neurosurgical practice, which presents different clinical characteristics compared with other more common lumbosacral variant. Since not much about this lesion has been reported in the literature, this study, herein, demonstrates by cases the clinical characteristics, methods, and techniques of surgical treatment of CMMC in children.

METHODS

A total of 10 children (six boys and four girls) with CMMC were recruited in this study. Their ages ranged from 9 days to 8 years with a median age of 3 months. All patients underwent neurological and radiological examinations. One was found to have had a mild unilateral arm weakness, and others were neurologically intact. Of these 10 patients, five had other associated neurological or orthopedic anomalies, including mild ventriculomegaly in two, cervical diastematomyelia in one, Chiari II malformation and hydrocephalus in one, and sacral spina bifida occulta in one. Surgical excision of the lesion with intradural exploration of the sac to release any potential adhesion bands was performed for all.

RESULTS

No complications, such as cerebrospinal fluid leakage and infection, had been found after operation. During the follow-up of 1-7 years (mean of 3.9 years), all cases did not suffer from aggravation of nervous symptoms. None of the patients deteriorated postoperatively, and the one with left arm weakness improved following surgery. In the two children with mild ventriculomegaly, cerebral ventricle returned to be normal after surgery.

CONCLUSIONS

The management strategies of CMMC are early surgical treatment with standard microneurosurgical techniques to prevent the development of neurological defects. It is safe and effective to adopt surgery excision of the lesions with intradural exploration of the sac to release any potential adhesion bands.

Cervical myelocystocele: prenatal diagnosis and therapeutical considerations

BACKGROUND

Cervical myelocystocele (CMC) is a very rare congenital malformation and belongs to the spectrum of skin-covered (occult) dysraphisms. Only 15 cases have been so far reported throughout the literature. We report the first case of CMC whose diagnosis was established prenatally by ultrasound imaging (US) followed by fetal magnetic resonance imaging (MR).

CASE HISTORY

A 35-year-old woman was referred for further investigations following prenatal assessment of a fetal cervical mass observed on routine US during pregnancy. Fetal karyotype was normal. Fetal MR confirmed the ultrasonographic findings and led us to strongly suspect the diagnosis of CMC. The newborn was operated on 2 months after birth. The goal of surgical procedure was to remove the malformation and to obtain an untethering of the spinal cord. Twelve months later, the child is still neurologically intact.

DISCUSSION

We discuss embryogenesis, different subtypes, associated malformations, and surgical strategy associated with myelocystoceles.

CONCLUSIONS

This case adds to the existing literature in that it shows for the first time antenatal images of this rare condition and discusses treatment and follow-up implications.

Terminal and nonterminal myelocystoceles

OBJECT

The purpose of this study was to report the author's experience with 14 cases of terminal and nine cases of nonterminal myelocystoceles and to highlight the differences between these two groups in regard to the embryological origins, clinical presentation, operative findings, results on neuroimaging studies, and prognosis for these lesions.

METHODS

This is a retrospective analysis of 14 cases of terminal and nine of nonterminal myelocystoceles treated between January 1998 and January 2006. All patients underwent neurological examination, plain x-ray films of the spine, computed tomography scans of the brain, and magnetic resonance (MR) imaging of the spine. In seven of these cases, MR imaging included three-dimensional constructive interference in steady-state sequences, and in four cases MR myelography was also done. Follow-up duration ranged from 3 months to 4 years.

RESULTS

All of the patients with terminal myelocystocele presented with swelling in the low back and varying degrees of neurological deficits, except four who had normal results on neurological tests. The MR images revealed classic features of terminal myelocystoceles in all patients. In each case, patients underwent excision of the meningocele sac and drainage of the syringocele with untethering of the spinal cord. During the last follow-up visit, there was no change in the neurological status of these children. In the nonterminal myelocystocele group, one lesion was cervical, six were thoracic, and two were lumbar lesions. All except one patient presented without neurological deficits; that patient had paraplegia with incontinence. Admission MR images revealed Rossi Type I nonterminal myelocystocele in six and Rossi Type II nonterminal myelocystocele in three patients. Children with Type I lesions underwent excision of the fibroneurovascular stalk and excision of the meningocele sac, whereas those with Type II lesions underwent drainage of the syringocele, untethering of the cord, and excision of the meningocele sac. There was no change in the neurological status postoperatively. During the follow-up period no patient in either group presented with retethering.

CONCLUSIONS

Myelocystoceles, both terminal and nonterminal, are different from other skin-covered masses in the back. A proper imaging evaluation is required to differentiate myelocystoceles from other skin-covered masses in this area, because the surgical treatment and prognosis are different for this subset of patients with occult spinal dysraphism. Terminal myelocystoceles are different from nonterminal ones embryologically, clinically, radiologically, surgically, and prognostically. These differences are discussed.

CERVICAL CONGENITAL MIDLINE MENINGOCELES IN ADULTS

OBJECTIVE

The clinical presentation, biomechanical evaluation, and surgical techniques for repairing cervical meningoceles in adulthood are presented. Cervical meningoceles are typically diagnosed in childhood and are rarely reported among spinal dysraphic lesions in adulthood. In most cases, the cervical spinal cord is found tethered to the dura and other soft tissues by fibrous or fibroneural elements. Cervical lesions, unlike those that arise more caudally, rarely leak cerebrospinal fluid.

METHODS

We report 5 male patients with meningoceles, aged 20 to 22 years (mean age, 20.4 years), in whom the primary evolution of the lesion occurred between 1999 and 2006.

RESULTS

All 5 patients presented to the hospital with cervical pain and mass. One patient had had a cerebrospinal fluid leak from the center of the lesion intermittently since birth. Another patient presented with neurological deficits and hypesthesia of the left hand. All patients underwent surgery. The lesion was excised, a partial laminectomy was performed, the internal tethering fibrous bands were released, and the neck of the structure was ligated. There was no neurological deterioration after surgery. No postoperative complications were observed during the 12-month follow-up period for each patient.

CONCLUSION

The goals of surgical exploration of these lesions are prevention of neurological deterioration, prevention of infection, and acceptable cosmetic outcome. Cervical meningoceles are tethering lesions of the spinal cord that may cause biomechanical injury with repetitive flexion-extension movements of the head and spine. It is therefore advisable to remove these lesions neurosurgically as soon as the diagnosis is made. Surgical intervention for cervical meningoceles should consist of exploration of the intradural fibrous bands with laminectomy, untethering of the spinal cord, and resection of the stalk and cyst of the meningocele.

Cervical myelomeningocele in adulthood: case report

OBJECTIVE

Cervical myelomeningocele is an extremely rare condition, accounting for only 1 to 5% of all neural tube defects. These lesions are usually diagnosed in childhood. Here, we report a case of a cervical myelomeningocele diagnosed and treated in adulthood.

CLINICAL PRESENTATION

A 52-year-old man presented with a 3-year history of progressing weakness and paresthesia in his upper limbs. Physical examination revealed a posterior midline neck mass covered with normal skin. Magnetic resonance imaging showed a soft-tissue mass tethering the cord by a stalk extending from the dorsal spinal cord to the dome of the lesion. Syrinx was evident cranially and caudally to the origin of the posterior stalk.

INTERVENTION

Surgical resection of the sac and intradural exploration were performed. The subdural space was explored, and the tethered structures were released. Histological examination showed small foci of meningothelial cells with psammoma bodies and rare thin fascicle of glial tissue dispersed in hyaline tissue. Immunohistochemical stains against glial fibrillary acidic protein and S100 confirmed the presence of bands of astrocytic tissue. The patient demonstrated early improvement of neurological deficits. Six months after surgery, he was asymptomatic and magnetic resonance imaging showed resolution of the syrinx.

CONCLUSION

We believe the syrinx in this patient was caused by a blockade of flow in the central canal and around the spinal cord as a result of the tethered cord. The untethering procedure resulted in the collapse of the syrinx followed by resolution of neurological deficits.

Giant true dorsal thoracic meningocele in a school-age child. Case report

A meningocele is a common form of spinal dysraphic lesions, but it is extremely uncommon in children in the upper thoracic region. The authors describe a rare case in which they found a giant true dorsal meningocele in the upper thoracic region in a symptomatic child, which, to their knowledge, is the first such reported case. A school-age child, who harbored a giant dorsal mass, complained of restriction of function. He underwent successful surgery in which the meningocele sac was totally removed.

Cervical meningomyelocele--an institutional experience

OBJECTIVE

Cervical myelomeningoceles (CMMC) are a less common but distinct subgroup of myelomeningoceles. Their embryology and clinical characteristics vary from the more common thoracolumbar variant. Only a few small series have been published addressing this lesion in the literature with the largest one of them addressing nine patients. The authors present one of the largest series of cervical myelomeningoceles, review their embryology, clinical features, and their management strategies.

METHODS

This study included all the children who were managed for cervical myelomeningocele between Jan 2001 to July 2006 at our center.

RESULTS

There were a total of ten children (five boys and five girls) operated on for cervical myelomeningoceles. The ages ranged between 2 months to 14 months. Neurological examination was normal in majority of the children with absence of gross orthopedic deformity in all the children. Three patients had associated hydrocephalus, two had Chiari malformation, and four of them had a syrinx. Surgical excision of the sac was performed for all.

CONCLUSION

Cystic dysraphisms of the cervical differ embryologically, clinically, and structurally from thoracolumbar meningomyelocele and have a more favorable outcome. A good pre operative evaluation is recommended to assess any associated anomalies and identify the internal structures. Surgery excision of these lesions with intradural exploration of the sac to release any potential adhesion bands as well as other associated anomalies is recommended.

Massive plexiform neurofibroma and spinal deformity presenting as dysphagia

Dysphagia is a symptom associated with various diseases of the upper gastrointestinal and respiratory tract, and it may be the presenting symptom of numerous tumors of the head and neck. Plexiform neurofibromas (PNFs) are benign tumors of the peripheral nerves and connective tissue, which are usually associated with neurofibromatosis type 1. We present a rare case of a 52-year-old woman presenting with dysphagia and weight loss due to a massive PNF in the subcutaneous adipose tissue of the posterior neck, associated with C1-C2 dislocation, scoliosis of the vertebral column, and 2 meningoceles consistent with the diagnosis of neurofibromatosis type 1. The combination of large PNF and cervical spine dysplasia may cause compression of the upper gastrointestinal tract and chronic progressive dysphagia.

Double spinal dysraphism. Report of three cases

The simultaneous presence of multiple spinal neural tube defects is unusual. There have been only a few of these cases reported in the literature. The authors report on three cases of double spina bifida cystica. One patient had two myelomeningoceles (MMCs) at the cervical and lumbosacral regions, one was noted to have both thoracolumbar and sacral defects, and the third presented with double MMCs at lumbar and lumbosacral levels. All three neonates in these cases underwent surgical treatment and ventriculoperitoneal (VP) shunt insertion for associated hydrocephalus. One child died at the age of 2 months despite a well-functioning VP shunt. The other two patients had no complications. Current models of neural tube closure do not thoroughly explain the mechanisms of multiple spinal dysraphism, but the multisite closure model provides a better understanding of caudal neural tube closure than other closure-site models.

Cervical meningocele causing symptoms in adulthood: case report and review of the literature

Simple meningoceles are infrequent forms of dysraphism and are often benign. These lesions are usually associated with other congenital spinal anomalies, and are typically diagnosed in childhood. Most become symptomatic in childhood because of progressive spinal cord or nerve root tethering. This article describes the case of a 47-year-old man who presented with a sac in his posterior cervical region that had been leaking colorless fluid for 3 months. He was also having difficulty walking and complained of stiffness in his lower extremities. Cervical magnetic resonance imaging revealed a cystic mass in the region of the C4 to C5 laminae. Partial laminectomies were performed (lower portion C4 lamina, upper portion C5 lamina), the sac was totally excised, and tissue tethering the spinal cord were cut. There was no recurrence of symptoms in 12 months of follow-up. Although in cases where a cervical meningocele-myelomeningocele is detected at any time, early treatment is essential to eliminate the high risk of future neurological impairment. This is the first report of an untreated cervical meningocele manifesting symptoms in adulthood.

The ‘human tail’ causing tethered cervical cord

STUDY DESIGN

Human tails continue to elicit curiosity till the present times. A unique case of human cervical dysraphism is described.

OBJECTIVES

In addition to the cosmetic stigma, these cutaneous markers provide a lead to reach the underlying spinal dysraphic states.

SETTING

Plains of North India.

METHODS

A case of human tail at the neck region is presented, whose cutaneous deformity lead the clinicians to his underlying spinal dysraphic state.

RESULTS

The final outcome of the patient was favorable.

CONCLUSION

Such markers should always be looked upon with a caution. The present report describes a unique case of a human neck tail, a causing cervical cord tethering.

Double myelomeningocele in a neonate: Case report and review of the literature

The presence of myelomeningocele at multiple levels along the spinal column is extremely rare. There are only a few cases of double myelomeningocele reported in the literature. We report the case of a newborn male who had two myelomeningoceles with one at the cervical level and the other at the lumbar level. This unusual case report as well as a review of the literature is presented.

Thoracic myelocystoceles--two variants

Myelocystoceles are rare lesions. Rarer still are thoracic myelocystoceles. Two patients with thoracic myelocystoceles are being reported. The first patient presented with swelling in the thoracic region with paraplegia and incontinence. MR with MR myelography revealed the malformation to be a thoracic myelocystocele. The second patient presented with a midline cutaneous mass lesion without neurological deficit. MRI revealed a Type I split cord malformation, a CSF containing sac in the thoracic region that communicated through a stalk-like structure to the hydromyelic hemicord. Surgery in both these patients did not produce any change in the neurological status. The importance of recognizing thoracic myelocystoceles, their clinical presentation, embryology, value of MR myelography in the diagnosis and role of surgery are discussed. The differences between terminal myelocystoceles and thoracic myelocystoceles are also highlighted.

Surgical technique and outcome in cervical and thoracic myelomeningocoele surgery

Cervical and thoracic myelomeningocoeles differ from common lumbosacral myelomeningocoeles in many respects. We review the surgical technique and outcome achieved for a series of six infants who underwent surgery for cervical or thoracic myelomeningocoele. Five patients, who had intradural exploration and microsurgical untethering of the spinal cord, were neurologically stable on follow-up. The other patient, who had a simple subcutaneous resection of the sac without release of the intradural tethering bands, was re-operated on 16 months later, with progressive neurological symptoms due to cord tethering. Following re-exploration and microsurgical untethering of the spinal cord, the neurological deficits significantly improved. We suggest that the surgical technique in these lesions should include careful intradural exploration and microsurgical release of the spinal cord by meticulous resection of all tethering bands. This enables postoperative neurological improvement and possible prevention of future neurological deficits due to cord tethering.

Cervical Myelomeningocele

OBJECTIVE:

Cervical myelomeningocele (cMMC) is a rare disease. Only a few series have been published regarding cMMC. Different issues regarding the etiology, classification, clinical, surgical, and pathological aspects of cMMC are still a matter of conflict.

METHODS:

Sixteen children operated on for cMMC between July 2000 and 2003 were followed by the neurosurgical service at Children's Hospital Medical Center in Tehran. The patients were followed up for 2 to 5 years (median, 3 yr).

RESULTS:

The studied patients were nine boys and seven girls, ages 1 day to 4 months. Neurological examination was normal in all but two patients. All children had a normal anal fold, could void spontaneously, and showed no evidence of gross orthopedic deformity. We found eight patients with hydrocephalus, four patients with Chiari II malformation, two patients with syringomyelia, one patient with diastematomyelia at the level of cervical hemimyelomeningocele, and one patient with associated sacral myeloschisis. A thorough urological evaluation was planned for 13 patients, which confirmed bladder dysfunction in 10 (71%) patients. All infants had midline lesions, which consisted of a protruding sac from the back of neck, covered with purplish rudimentary or dysplastic skin at the dome. All patients underwent surgical resection of the sac and intradural exploration to release any adhesion and to exclude other associated anomalies.

CONCLUSION:

Cervical myelomeningocele differs structurally and clinically from myelomeningocele in distal areas and has a more favorable outcome. We think that some trivial neurological deficits in cMMC are caused by the late and limited neurulation abnormality during its development. We advise thorough preoperative evaluation of the brain, spinal column, and urinary system. Intradural exploration to release any potential adhesion bands as well as correcting associated anomalies is recommended in all cMMC operations.

Cervical spina bifida cystica: MRI differentiation of the subtypes in children

BACKGROUND

Cervical spinal dysraphism is a rare condition with only 37 cases reported in the literature, of which only seven patients had undergone preoperative magnetic resonance imaging (MRI).

OBJECTIVE

By using illustrative cases, we demonstrate the value of MRI in distinguishing the two different subtypes of cervical spinal dysraphism, namely, myelocystocele and meningocele.

METHOD

Retrospective review of the MRI scans of six patients with cervical (one high thoracic) posterior cystic swellings, which were diagnosed as cervical dysraphism, was done.

RESULTS

Three patients were diagnosed with myelocystocele and three patients with meningocele. A comparison of MRI features between the two entities, as well as the associated anomalies, is discussed.

CONCLUSION

MRI is the imaging modality of choice for suspected cervical dysraphism, prior to surgery. It helps distinguish the subtypes, as well as identify the associated anomalies.

Cystic spinal dysraphism of the cervical and upper thoracic region

BACKGROUND

Cystic dysraphic lesions of the cervical and upper thoracic region are rare and only a few series have been published about the topic. These malformations can be divided into categories that include both myelocystoceles and the so-called cervical meningoceles or myelomeningoceles.

METHODS

A retrospective study of 18 patients was conducted.

RESULTS

In 17 patients a squamous or a cicatricial epithelium of variable thickness covered the dome of the lesions, while the base was covered with full-thickness skin. In one case the skin was entirely normal. Four patients displayed associated CNS malformations and three more had systemic congenital anomalies. All patients underwent surgical exploration and the length of time between birth and surgery ranged from 6 h to 9 months. The most frequent surgical finding, seen in 14 patients, was a stalk connecting the dorsal surface of the spinal cord to the cyst. In three patients the findings were consistent with myelocystocele. Only in one case was a true meningocele found. Hydrocephalus and Chiari II malformation were not as consistently associated as in myelomeningoceles. Neurological signs and symptoms were not so marked as in myelomeningoceles and were found in the follow-up of four patients. In two of them there was a non-progressive deficit, probably expressing an imperceptible involvement of the nervous system in the first year of life. The histopathological findings were of three types: neuroglial stalks, fibrovascular stalks and myelocystoceles.

CONCLUSIONS

Cystic dysraphisms of the cervical and upper thoracic region differ clinically and structurally from meningomyelocele and have a more favorable outcome. We believe that these malformations have not been properly labeled and propose a classification based on the structures found inside the cyst.

Triple neural tube defect--cranium bifidum with rostral and caudal spina bifida--live evidence of multi-site closure of the neural tube in humans

OBJECTIVE

The coexistence of three neural tube defects (NTDs) in a single child is an exceptional event. A review of the literature revealed nine published "double" NTD cases, but no cases of "triple" NTDs have been reported to date.

CASE REPORT

The rare case of a two-year-old boy with three distinct NTDs is presented. The boy had a 17x15x15-cm(3) parieto-occipital encephalocele, a small cervical myelomeningocele, and a 11x11x8-cm(3) thoracolumbar myelomeningocele. Hydrocephalus and Chiari II malformation accompanied the NTDs. All three lesions were surgically treated with good cosmetic results and satisfactory neurologic outcome.

CONCLUSIONS

Current neural tube closure theories and models are reviewed in an attempt to better understand this extremely unusual coexistence. The multi-site closure model is clearly more useful in our understanding of NTDs.

Cervical meningocele in association with spinal abnormalities

CASE REPORT

This case report presents a newborn baby girl, who was diagnosed at birth with a mid-cervical meningocele. Further radiographic workup by MRI revealed co-existing thoracic diplomyelia and bilateral tethered cords. At birth the patient was found to be neurologically intact. Surgery was performed at 4 months of age, the patient undergoing simultaneous repair of the cervical meningocele, exploration of the diplomyelia, and release of the tethered cords bilaterally. Long-term follow-up revealed an ambulating patient with no bowel or bladder incontinence, who has developed well for her chronological age so far.

REVIEW OF THE LITERATURE

A review of the literature relevant to this case is also presented.

The initial treatment of meningocele and myelomeningocele lesions in adulthood: experiences with seven patients

This is a retrospective study of patients having undergone surgical treatment of spina bifida cystica (SBC) lesions in adulthood. The objectives were to assess the clinical, radiological, and surgical characteristics of SBC lesions in adults. There is almost no study assessing these characteristics. Seven adult male patients with SBC lesions, ages between 20 and 23 (mean 21.1), had their primary evaluations between 1995 and 1999 in the Military Hospital, Yzmir, and Gülhane Military Medical Academy, Ankara. A temporary cerebrospinal fluid leak in the patient with the thoracic lesion and a temporary partial urinary incontinence in the patient with the lumbosacral lesion occurred. The most common preoperative complaint was low back pain. This improved in three of four patients (75%) but did not disappear. Although it is rare, an adult with an untreated SBC is a possible entity. These lesions should be included in the differential diagnosis of dorsal midline lesions in adults. Even though they appear as a simple spinal meningocele clinically, preoperative MR imaging and CT are necessary and helpful in the precise diagnosis and surgical planning.

Diastematomyelia with terminal lipomyelocystocele arising from one hemicord: case report

Diastematomyelia is an uncommon spinal dysraphism with midline dorsoventral clefting of the spinal cord. Formation of syrinx cavity within the hemicord, vertebral anomalies and lipomas is known to be associated with diastematomyelia. We present an unusual case of a 4-month-old girl, who presented with diastematomyelia and terminal myelocystocele, and dilatation of the terminal portion of the spinal canal with formation of a cystic structure. Findings were confirmed by subsequent surgery and histopathology. Ectopic right kidney, Chiari I malformation and changes of partial sacral agenesis were other findings noted in this case. No case report of formation of terminal myelocystocele arising from one hemicord was described in the literature we reviewed.

Cervical myelomeningocele--follow-up of five patients

Only a few series of patients with cervical myelomenigocele (cMMC) and cervical meningocele (cMC) have been published. Interventions as well as the neurologic, orthopaedic, urologic and intellectual outcomes were analysed in this retrospective description of five patients with cMMC and cMC diagnosed in the period 1984-1999. Four patients suffered from cMMC, one from cMC. The average duration of follow-up was 9.5 years. None of the patients had periconceptual prevention with folic acid. Three had a Chiari II malformation and two a hydrocephalus. Tethering of the cervical cord was demonstrated in three patients at follow-up. All children achieved an independent ambulatory function and urinary continence. Incomplete sensorimotor hemiparesis was present in two children, and a mild unilateral arm paresis in one. Two of five patients had age appropriate cognitive functions. Three patients with mild mental retardation or behavioural problems had to be placed in special classes. The outcome of patients with cMMC is favourable regarding to the neurologic, orthopaedic and urologic problems compared with lower neural tube defects. However, the burden of repeated examinations and therapies is considerable and induces high costs, therefore prevention with periconceptual folic acid is a crucial issue also in cMMC. Spinal cord dysfunction has to be considered in growing children due to persistent tethering or re-tethering, therefore regular neurologic and urodynamic investigations are of particular importance.

Prenatal diagnosis of a fetus with lumbar myelocystocele

We present a case of a fetal lumbar myelocystocele, a rare congenital malformation, characterized by herniation of the central canal through a bony spina bifida. Routine ultrasound examination at 11 weeks' gestation by the primary obstetrician showed a suspicious cyst on the fetal back. Initially, the suspected diagnosis was a meningocele. After sonographic detection of newly developed fetal brain anomalies at 22 weeks' gestation the patient was referred to us. The enlarged cyst, which floated freely in the amniotic fluid, had a funnel-like appearance and was covered by a very thin layer of skin. With the help of ultrafast fetal magnetic resonance imaging the diagnosis of a fetal myelocystocele was made.