AIUM practice guideline for the performance of an ultrasound examination of the neonatal spine

Midline cutaneous anomalies of the craniospinal axis

Patients with midline cutaneous anomalies of the craniospinal axis can be indicative of underlying embryonic defects, such as neural tube defects. Lack of familiarity with these midline aberrant skin findings may lead to misdiagnosis and delayed treatment. In this review, midline cutaneous anomalies of the craniospinal axis including aplasia cutis congenita, cranial and spinal dysraphism, and other developmental anomalies are explored in detail with emphasis on cutaneous clues to the diagnosis and appropriate workup.

Neonatal and infantile spinal sonography: A useful investigation often underutilized

Sonography is an ideal, effective, noninvasive tool for evaluation of the spinal cord in neonatal and early infantile age groups owing to lack of ossification of the posterior elements of spine. Understanding normal anatomical appearances is a prerequisite for the interpretation of various pathologies of the spinal canal and its contents. This review elucidates normal appearances of the spinal cord in this age group, in both axial and sagittal planes. Usefulness of Doppler sonography is briefly discussed, and special emphasis is placed on normal anatomical variants that may mimic spinal abnormalities. Sonographic appearances of common intraspinal pathologies, both congenital and acquired, are exhaustively described. Key points regarding sonographic diagnosis of important spinal anomalies are emphasized and explained in detail. To conclude, spinal ultrasound is a reliable and widely available screening tool, albeit the usefulness of which is often underestimated.

Spinal ultrasound after failed landmarked-based lumbar puncture: a single institutional experience

BACKGROUND

The safety and efficacy of US-guided lumbar puncture in children has been described. In the pediatric setting, children are frequently referred to interventional radiology only after a failed landmark-based attempt. Routine pre-procedure US in these children is useful to determine a safe level for subarachnoid access and to optimize success.

OBJECTIVE

To determine whether pre-procedure US improves technical success and safety of US-guided lumbar puncture.

MATERIALS AND METHODS

We included 47 children. Inclusion criteria were urgent US-guided lumbar puncture in pediatric patients <18 years old. Exclusion criteria were non-urgent lumbar punctures, children referred without an antecedent landmark-based attempt, lumbar punctures performed with fluoroscopic guidance, and procedures performed prior to introducing the diagnostic approach in 2017. We did not evaluate data pertaining to successful landmark-based lumbar punctures performed without subsequent need for additional attempts. We recorded technical successes, adverse events and relevant abnormalities identified on pre-procedural US.

RESULTS

Thirty-six US-guided lumbar punctures were performed with 100% technical success. Eleven children referred to interventional radiology did not undergo lumbar puncture because of unfavorable US findings or interval clinical improvement obviating the need for lumbar puncture. Thirty-six children underwent US evaluation of the thecal sac prior to potential intervention. Of these 36 with pre-procedural US studies, 12 demonstrated paucity of cerebrospinal fluid and 14 demonstrated an epidural hematoma. Fifteen children who underwent lumbar puncture had a "traumatic tap," classified as a mild adverse event. No moderate or severe adverse events were recorded.

CONCLUSION

Limited spinal US following failed landmark-based lumbar punctures frequently identifies procedure-related complications and can augment patient selection for future image-guided lumbar punctures.

Pediatric Spinal Ultrasound: Neonatal and Intraoperative Applications

The purpose of this article is to review the use of ultrasound as a screening tool for spinal diseases in neonates and infants and its intraoperative value in selected pediatric neurosurgical disorders. A review of spinal embryology followed by a description of common spinal diseases in neonates assessed with ultrasound is presented. Indications for spinal ultrasound in neonates, commonly identified conditions, and the importance of magnetic resonance imaging in selected cases are emphasized. Additionally, the use of ultrasound in selected neurosurgical spinal diseases in pediatric patients is presented with magnetic resonance imaging and intraoperative correlation. Technique, limitations, and pitfalls are discussed.

Ultrasound Examination of Pediatric Musculoskeletal Diseases and Neonatal Spine

Ultrasound (US) is a simple, non-invasive imaging modality which allows high-resolution imaging of the musculoskeletal (MSK) system. Its increasing popularity in pediatrics is due to the fact that it does not involve radiation, has an ability to visualize non-ossified cartilaginous and vascular structures, allows dynamic imaging and quick contralateral comparison. US is the primary imaging modality in some pediatric MSK conditions like infant hip in developmental dysplasia (DDH), hip joint effusion, epiphyseal trauma and evaluation of the neonatal spine. US is the modality of choice in infants with DDH, both in the initial evaluation and post-treatment follow-up. US has a sensitivity equivalent to MRI in evaluation of the neonatal spine in experienced hands and is a good screening modality in neonates with suspected occult neural tube defects. In other MSK applications, it is often used for the initial diagnosis or in addition to other imaging modalities. In trauma and infections, US can often detect early and subtle soft tissue abnormalities and a quick comparison with the contralateral side aids in diagnoses. Dynamic imaging is crucial in evaluating congenital instabilities and dislocations, soft tissue and ligamentous injuries, epiphyseal injuries and fracture separations. High-resolution imaging along with color Doppler (CD) is useful in the characterization of soft tissue masses. This article reviews the applications of US in pediatric MSK with emphasis on conditions where it is a primary modality. Limitations of US include inability to penetrate bone, hence, limited diagnosis of intraosseous pathology and operator dependency.

[Sacral dimple: What form of management is best?]

A sacral dimple measuring less than 5mm, within 25mm of the anus on the median line, with no other cutaneous anomaly, does not require any complementary examination. Parents can be reassured. However, any cutaneous depression in the sacrolumbar region not respecting these criteria must be considered as an occult dysraphism until proved otherwise. A medullary ultrasound examination and a consultation with a specialist (pediatric neurosurgeon) are necessary. The dermic sinus is the main differential diagnosis, with favorable outcome in case of early treatment before any infectious complication arises. Conversely, the risk of permanent sequelae is high if neglected or in case of late diagnosis.

Neural tube dysraphism: review of cutaneous markers and imaging

Neural tube dysraphisms are congenital anomalies resulting from impaired formation of structures along the craniospinal axis during central nervous system development. When these malformations are large or lack a skin covering, they are easily recognized, whereas smaller or skin-covered malformations may not be readily apparent. Due to the intimate embryologic origin of the skin and nervous system, these occult malformations are often heralded by associated cutaneous abnormalities. In this article, the common clinical presentations and cutaneous markers of craniospinal dysraphism are reviewed, along with the recommended imaging modalities.