Prevesicular herpes zoster lumbar radiculopathy with transient motor paresis: A case report

RATIONALE

Herpes zoster frequently causes dermatomal vesicular rash accompanied by severe neuralgia, and reaching a differential diagnosis may be challenging before the appearance of the vesicular rash.

PATIENT CONCERNS

A 40-year-old male patient visited the emergency department with a complaint of sudden onset motor weakness and ipsilateral radiating neuralgia to the Lt. thigh. He had suffered from chickenpox during childhood.

DIAGNOSES

No skin lesion was present at the initial visit. The reverse Straight Leg Raise test was negative. Magnetic resonance imaging showed asymmetrically swollen dorsal root ganglion with Gadolinium enhancement. The vesicular rash that appeared on the sixth day after the symptom onset led to the diagnosis of herpes zoster.

INTERVENTIONS

Antiviral agent of valacyclovir (1000 mg t.i.d.) was administered for 7 days.

OUTCOMES

The patient recovered from motor weaknesses by 2 weeks from the onset of the symptom. Mild degree post-herpetic neuralgia recovered by 2 months.

LESSONS

A high index of suspicion is necessary to differentiate early herpes zoster radiculitis before the appearance of vesicular rash from compressive radiculopathy. In L2-3 ipsilateral radiating pain along the dermatome or myotome, the absence of reverse Straight Leg Raise sign may be a possible factor in differentiating herpes zoster radiculitis from compressive radiculopathy.

Retroperitoneoscopic debridement and internal fixation for the treatment of lumbar tuberculosis

To describe the retroperitoneoscopic debridement technique and evaluate the clinical outcome of internal fixation for the treatment of lumbar tuberculosis.Twenty-eight patients were performed conventional laparoendoscopic technique (n = 17) or laparoendoscopic single-site technique (n = 11). Antituberculosis chemotherapy and thoracolumbosacral orthosis were given to all patients. The clinical outcomes were evaluated with preoperative and postoperative Visual Analog Scale, and radiographs with respect to sagittal angle and fusion status.Average time of the 28 procedures was 220.6 ± 50.9 min (180-365 min). The average intraoperative blood loss was 108.6 ± 95.3 mL (50-400 mL). All patients showed significant improvement of their Visual Analog Scale back pain score at follow-up and were classified as having a radiographic fusion in this study. The mean sagittal angle was 11.2 ± 3.6° before operation, significantly improved to 3.7 ± 2.4° after operation. There were no recurrent infections during the follow-up period. Complications included loosening of anterior fixation and temporary deficit of the sympathetic nerve.Retroperitoneal laparoscopic approach with CO2 insufflation technique is a challenging but safe and effective procedure for lumbar spine tuberculosis. Retroperitoneal laparoendoscopic single-site can be used for anterior lumbar spine surgery, offer exposure for L1 through L5.

Outcome of lumbar lateral recess stenosis with percutaneous endoscopic transforaminal decompression in patients 65 years of age or older and in younger patients

Lateral recess stenosis is a common pathology causing clinical syndromes in the elderly population, and there is some concern regarding the number of comorbidities that can occur when performing surgery for this condition in the elderly. However, little research has focused on the issues related to older age, and limited data is available to help the clinician counsel elderly patients undergoing percutaneous endoscopic transforaminal decompression. The present study aimed to explore the safety and efficacy of percutaneous endoscopic transforaminal decompression for lumbar degenerative disease in elderly patients with lumbar lateral recess stenosis and to determine whether age and comorbidity affect the outcome and complication rate.We identified 117 patients in our patient database who underwent percutaneous endoscopic transforaminal decompression for single-level lumbar lateral recess stenosis. Data regarding the Oswestry Disability Index and visual analog scale for back and leg pain were collected preoperatively, postoperatively, and at the last follow-up. Other data, including preoperative comorbidities, operation time, and intraoperative and postoperative complications, were recorded.The average follow-up period was 29.9 ± 5.5 months, with a mean age of 69.8 ± 5.4 years in elderly patients (group A) and 50.4 ± 6.4 years in younger patients (group B). Group A had a higher percentage of comorbidity than group B (83.9% vs 18.0%, P < .001). Both visual analog scale scores for leg pain and Oswestry Disability Index were significantly improved in the 2 groups, and no difference was found between the groups regarding both parameters (P >.05). The elderly patients had the same high rate of favorable outcomes as group B (P > .05). Moreover, there was no difference in surgical complications, recurrence, and neurologic deficit recovery rate between both groups. No major complications or perioperative deaths occurred in both groups.The present study demonstrates that percutaneous endoscopic transforaminal decompression for lateral recess stenosis in elderly patients may be a reasonable treatment associated with substantial benefit.

Surgical stabilization of spinal metastasis in diffuse idiopathic skeletal hyperostosis ("Mets-on-DISH"): Two case reports

RATIONALE

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ossification along the anterolateral aspect of at least 4 contiguous vertebral bodies. A fracture involving the fused vertebra in patients with DISH often leads to severe instability and spinal cord injury. Spinal metastasis (Mets) and DISH can coexist in elderly patients and increase their risk of pathologic vertebral fractures. However, there are few reports on concomitant spinal Mets and DISH.

PATIENT CONCERNS

A 78-year-old man who complained of gradual onset of paraparesis, sensory loss below the umbilicus, and incontinence (case 1) and a 63-year-old woman who complained of severe back pain and urinary incontinence (case 2).

DIAGNOSIS

Two patients were diagnosed with spinal Mets and DISH.

INTERVENTIONS

Decompression surgery was performed at the metastatic sites in case 1 whereas instrumentation surgery was performed in case 2 despite the fracture having a benign appearance with no associated neurologic symptoms.

OUTCOMES

A vertebral fracture developed at the metastatic vertebra after decompression surgery in case 1. Severe instability of the surgical site in this case resulted in persistent paralysis even after subsequent revision surgery with instrumentation. In contrast, the clinical course was benign without any neurologic dysfunction at the 2-year follow-up in case 2.

LESSONS

Instrumentation surgery should be performed in patients with DISH who develop spinal Mets even if there is no apparent instability.

Functional Changes in Patients and Morphological Changes in the Lumbar Intervertebral Disc after Applying Lordotic Curve-Controlled Traction: A Double-Blind Randomized Controlled Study

Background and Objectives: Lumbar traction is widely used as a non-operative treatment for lumbar intervertebral disc disease. The effect of traditional traction (TT) using linear-type traction devices remains controversial for various reasons, including technical limitations. Thus, the purpose of this study was to compare the effects of the newly developed lumbar lordotic curve-controlled traction (L-LCCT) and TT on functional changes in patients and morphological changes in the vertebral disc. Materials and Methods: A total of 40 patients with lumbar intervertebral disc disease at the L4/5 or L5/S1 level as confirmed by magnetic resonance imaging were recruited and divided into two groups (L-LCCT or TT). The comprehensive health status changes of the patients were recorded using pain and functional scores (the visual analogue scale, the Oswestry Disability Index, and the Roland–Morris Disability Questionnaire) and morphological changes (in the lumbar central canal area) before and after traction treatment. Results: Pain scores were significantly decreased after traction in both groups (p < 0.05). However, functional scores and morphological changes improved significantly after treatment in the L-LCCT group only (p < 0.05). Conclusions: We suggest that L-LCCT is a viable option for resolving the technical limitations of TT by maintaining the lumbar lordotic curve in patients with lumbar intervertebral disc disease.

The Termination Level of the Dural Sac Relevant to Caudal Epidural Block in Lumbosacral Transitional Vertebrae: A Comparison between Sacralization and Lumbarization Groups

BACKGROUND

Lumbosacral transitional vertebrae (LSTV) are a relatively common variant and have been considered as one of the reasons for back pain. It is not unusual for clinicians to encounter patients with LSTV who require caudal epidural block (CEB) for pain management.

OBJECTIVE

We investigated the termination level of the dural sac (DS) and anatomical features of the lumbosacral region relevant to CEB in patients with LSTV and compared these findings between sacralization and lumbarization groups.

STUDY DESIGN

A retrospective evaluation.

SETTING

A university hospital with inpatient and outpatient LSTV cases presenting low back pain.

METHODS

Four hundred ninety-four LSTV patients were included and categorized into sacralization (n = 201) or lumbarization groups (n = 293). Magnetic resonance imaging (MRI) of all of the LSTV patients were reviewed to determine the level of DS termination, the shortest distance between the apex of the sacral hiatus and DS, and the presence and the caudal level of sacral perineural cysts. Each lumbosacral vertebra column was divided into 3 equal portions (upper, middle, and lower thirds). The MRI findings in both of the groups were compared and analyzed.

RESULTS

The distribution frequency of the levels of DS termination demonstrated a significant difference between the 2 groups. The mean caudal DS level in the lumbarization group was significantly lower than the sacralization group (lower third of the S2 [131 {44.7%} of 293 patients] vs. lower third of the S1 [78 {38.8%} of 201 patients]). The DS terminated at the S3 in more than 19% of the lumbarization group, whereas in only one case of the sacralization group. Although the incidence of perineural cysts was not significantly different between the 2 groups, the mean level of caudal margin of perineural cysts in the lumbarization group was significantly lower than the sacralization group (middle third of the S3 [10 {35.7%} of 28 cases] vs. middle third of the S2 [11 {44%} of 25 cases]).

LIMITATIONS

This study reveals several limitations including the practical challenge of accurate enumeration of the transitional segment and the constraints on generalizability posed by the single-country study.

CONCLUSION

When planning CEB for patients with LSTV, pre-procedural MRI to check the anatomical structures, including the level of DS termination and caudal margin of perineural cysts, would be of great use for lowering the risk of unexpected dural puncture during the procedure, especially in the lumbarization cases.

KEY WORDS

Termination of the dural sac, dural sac termination, lumbosacral transitional vertebrae, transitional vertebra, caudal epidural block.

One-stage posterior excision of lumbosacral hemivertebrae: Retrospective study of case series and literature review

Lumbosacral hemivertebrae causes unique problems as early trunk decompensation and long compensatory curve above. There are only a few reports on it. This case series is a fair supplement in the literatures.To evaluate the clinical and radiological outcomes of lumbosacral hemivertebrae resection through 1-stage posterior approach.Between 2005 and 2014, a consecutive series of congenital scoliosis due to lumbosacral hemivertebrae underwent hemivertebrae excision through 1-stage posterior only approach. Demographic, operative, radiological, and quality of life data were reviewed.The mean lumbosacral curve was 29 ± 7° preoperatively, 10 ± 3° postoperatively, and 13 ± 5° at the final follow up. The final correction rate was 55 ± 9%. The gravity trunk shift was 11 ± 3 mm preoperatively, 37 ± 12 mm (range, 6-49 mm) postoperatively, 14 ± 9 mm at final follow up. The rib cage shift was 36 ± 12 mm preoperatively, 19 ± 5 mm postoperatively, and 15 ± 4 mm at the final follow up. The mean blood loss was 527 ± 125 mL and the mean surgery time was 336 ± 98 minutes. The mean follow up period was 41 ± 6 months. Two patients underwent transient neurological complications, 2 had wound bad healing, and 1 got wound infection. No pseudoarthrosis and instrumentation failure was observed.One-stage posterior hemivertebrae excision could gain reasonable outcome. It is crucial to completely resect the hemivertebrae and the Y-shaped disc. Bending the rod to appropriate lordosis is helpful to close the convex side. Early surgical intervene is a preferred choice to restore the trunk balance and avoid extensive fusion. The neurological complication rate is high. Convex radiculopathy is often caused by retraction, it could recover at follow up.

BIOMECHANICS OF THERAPEUTIC RIDING DURING THE DISEASES OF I-II DEGREE DYSPLASTIC LUMBAR AND STATIC (SHORT LEG) SCOLIOSIS

The goal of the paper is to substantiate the essence of ridetherapy biomechanics as the pathogenetic therapeutic and prophylactic method at lumbar dysplastic (the I and II degrees) and static (short-legged induced) scoliosis. Uneven lower extremities caused by any reason and asymmetric support induce the change in the arrangement of trochantin to the vertebra and correspondingly the uneven loading of lumbar muscles. The asymmetric strength of lumbar muscles evoked by the change in rotator condition becomes the cause of the formation of scoliosis primary arc which, in its turn, causes a compensatory spinal curvature. In case of dysplastic scoliosis a leading role belongs to the beginning of dystrophic changes in intervertebral discs and its further decentration. At riding position the lower extremities are completely disengaged from the antigravity redistribution, the child is in direct contact with vibrations and jolts coming from the horseback; the antigravity loading is distributed on the muscles of the torso and thus, it creates an opportunity to purposefully affect the correction of the spine. During scoliosis the pathogenic essence of ridetherapy is due to the comprehensiveness of its procedures, expressed in the fact that during one procedure several factors are influenced simultaneously: nucleus pulpous, the torso and iliopsoas muscles, the antigravity system, etc. According to the clinical-functional and radiographic studies carried out in the dynamics on 11-16 years old adolescents it has been established that in those groups where the rehabilitation was conducted in a complex with ridetherapy the authentically higher results were obtained as compared to the groups where the rehabilitation was held using therapeutic exercises and massage.

Impact of introduction of mid-trimester scan on pregnancy outcome of open spina bifida in The Netherlands

OBJECTIVE

To examine the impact of introduction of the mid-trimester scan on pregnancy outcome in cases of open spina bifida in two regions of The Netherlands.

METHODS

This was a retrospective cohort study of 190 cases of open spina bifida diagnosed pre- or postnatally, with an estimated date of delivery between 2003 and 2011.

RESULTS

With implementation of the mid-trimester scan the percentage of cases of open spina bifida detected before the 24(th) week of pregnancy increased from 43% to 88%. The rise in prenatal detection rate was associated with a significant increase in the number of terminated pregnancies and a decrease in the rate of perinatal loss; the percentage of children born alive did not change significantly. In the subgroup that underwent a scan between 18 and 24 weeks of pregnancy, cranial signs were present in 94.4% of cases.

CONCLUSION

Introduction of the mid-trimester scan has led to an increase in early identification of pregnancies complicated by open spina bifida. Pregnancies previously destined to end in perinatal loss are now terminated whilst pregnancies with a relatively good prognosis are frequently continued; the number of children with open spina bifida who are born alive has not changed significantly. Our study confirms that prenatal diagnosis is usually triggered by visualization of a lemon-shaped skull or a banana-shaped cerebellum.

Developmental malformations in the area of the lumbosacral transitional vertebrae and sacrum: differences in gender and left/right distribution

PURPOSE

The aim of this study was to determine the incidence of congenital malformations of the lumbosacral transitional vertebrae in the general population, and the differences in their gender and left/right distributions.

METHODS

The examined group comprised of all patients who underwent a pelvic X-ray during 2010 for any reason. The observed parameters included the following malformations: the presence of megatransversus at L5; sacralization of L5 or L6; a S1 lumbarization; the presence of six sacral vertebrae; or spina bifida at the level of L5, S1 or S2. In cases of megatransversus at L5, the lateral distribution was recorded. A total of 1,513 images were evaluated. Sex and lateral differences were evaluated using the Pearson's (χ (2)) test with a significance level of 5 %.

RESULTS AND CONCLUSIONS

A total of 478 malformations were found in 417 patients, which constituted 27.6 % of the entire group. Malformations occurred in 250 women (25.4 % of all women) and 167 men (31.6 % of all men) and the female to male ratio in affected individuals was 1.5:1. The predominance of the occurrence of malformations observed in men was statistically significant (p = 0.009). The most frequently occurring malformations were the presence of six sacral vertebrae (179 patients) and megatransversus at L5 (150 patients). The study confirmed a high incidence of congenital malformations in the area of the lumbosacral transitional vertebrae and demonstrated a higher incidence in males. Unilaterally occurring megatransversus at L5 was significantly more common on the left side.

The longest faun tail forming dreadlocks with underlying spina bifida occulta

Spina bifida is a developmental anomaly characterized by defective closure of the bony encasement of the spinal cord through which the spinal cord and meninges may or may not protrude. We report a rare case of a very long faun tail, which was in the form of a 20 inch long tail originating from the lumbosacral area in a rhomboidal pattern, measuring 10 x 8 inches. The case is being reported for its rare presentation of a 20 inch long faun tail with underlying spina bifida occulta.

[Electrophysiologial evaluation of ozone in treating of lumbar disc herniation with curving sheath-needle multi-direction rotating injection]

OBJECTIVE

To compare electrophysiological changes in treating lumbar disc herniation (LDH) with ozone by curving sheath-needle multi-direction rotating injection (CSNMRI) and conventional injection method.

METHODS

From May 2005 to June 2009,100 patients with LDH were studied, included 68 males and 32 females, ranging in age from 25 to 58 years with an average of 44 years, in course of disease from 3 months to 8 years with an average of 8.8 months. All patients were numbered according to sequence of visit, and were completely randomly divided into group A and group B with DPS software, 50 cases in each group. All patients were injected ozone into lesion of intervertebral disc, in group A with CSNMRI and in group B with conventional method. The electrophysiologic study of all patients was performed respectively before treatment and at the 3 month after treatment. The electromyogram (EMG) of the main muscle groups of involved lower limb and the corresponding segments of sacrospinal muscle was tested; the duration and multiphase-wave rate of MUP were calculated. H-reflex of tibial nerve in both lower limbs was observed and the number of abnormal H-reflex and the H-wave latency were recorded.

RESULTS

After treatment, the number of muscles with abnormal EMG was reduced to different degrees in each group, but there was more significant reduction in group A (P < 0.05 or 0.01); the duration and multiphase-wave rate of MUP in the two groups were both reduced and close to the normal level (P < 0.01), yet the changes in group A was more than that of group B (P < 0.05 or 0.01). There was no significant difference in the number of abnormal H-reflex before treatment between two groups, whereas was markedly lower in group A than that of group B after treatment (P < 0.05). After treatment, H-wave latency in two groups was shortened and become close to normal, but group B was more statistically significant than group B (P < 0.05).

CONCLUSION

The neural electrophysiological abnormalities can reflect the degree of nerve root compression and damage, and is one of the objective indicators to estimate neuromuscular function. It can better meliorate abnormal electrophysiology to inject ozone to treat LDH with CSNMRI than conventional method.

Assessment of intracranial translucency (IT) in the detection of spina bifida at the 11-13-week scan

OBJECTIVE

Prenatal diagnosis of open spina bifida is carried out by ultrasound examination in the second trimester of pregnancy. The diagnosis is suspected by the presence of a 'lemon-shaped' head and a 'banana-shaped' cerebellum, thought to be consequences of caudal displacement of the hindbrain. The aim of the study was to determine whether in fetuses with spina bifida this displacement of the brain is evident from the first trimester of pregnancy.

METHODS

In women undergoing routine ultrasound examination at 11-13 weeks' gestation as part of screening for chromosomal abnormalities, a mid-sagittal view of the fetal face was obtained to measure nuchal translucency thickness and assess the nasal bone. In this view the fourth ventricle, which presents as an intracranial translucency (IT) between the brain stem and choroid plexus, is easily visible. We measured the anteroposterior diameter of the fourth ventricle in 200 normal fetuses and in four fetuses with spina bifida.

RESULTS

In the normal fetuses the fourth ventricle was always visible and the median anteroposterior diameter increased from 1.5 mm at a crown-rump length (CRL) of 45 mm to 2.5 mm at a CRL of 84 mm. In the four fetuses with spina bifida the ventricle was compressed by the caudally displaced hindbrain and no IT could be seen.

CONCLUSION

The mid-sagittal view of the face as routinely used in screening for chromosomal defects can also be used for early detection of open spina bifida.

Incidence and patterns of lumbosacral transitional vertebrae, in patients with low backpain in a Nigerian hospital

BACKGROUND

Lumbosacral transitional vertebrae (LSTV), is a structural anomaly, of the lumbosacral spine which has been variably associated with, low back pain (LBP) and its presence can also result in a level being wrongly identified pre-operatively.

OBJECTIVES

To determine the incidence, pattern of LSTV and its relationship with LBP in our tertiary hospital.

METHODS

A retrospective review of lumbosacral spine radiographs of 561 one consecutive patients with history of LBP was done from January 2006 to January 2008. The presence or absence of LSTV and degenerative changes were documented.

RESULTS

Fifty-one ((9.1%)) out of 561 patients had LSTV. Type II (incomplete) LSTV was the commonest type, occurring in 86.3% of patient with LSTV. Patients less than 30yrs with LBP and LSTV had no degenerative changes, while all patients with LSTV above 50 yrs had degenerative changes.

CONCLUSION

Lumbosacral transitional vertebrae type II was the commonest seen in this study, furthermore, LSTV appears to be a causative factor of LBP in young individuals. Careful evaluation of spinal radiographs of patients with LBP belonging to this group is advocated to assess for the presence or absence of LSTV.

Closure of the defect resulting from caudal regression syndrome with duplicated rectum

Caudal regression syndrome covers a range of congenital malformations that range from simple anal atresia to absence of sacral, lumbar, and possibly lower thoracic, vertebrae. To the best of our knowledge, this is the first case of caudal regression syndrome combined with rectal duplication. We present a case and describe our technique of reconstruction.

[Caudal regression syndrome--two case reports]

OBJECTIVE

The authors demonstrate two cases of caudal regression syndrome (CRS), a rare malformative syndrom, seen mainly in cases of maternal diabetes with poor metabolic control.

DESIGN

Case report.

SETTING

Department of Obstetrics and Gynecology, Department of Medicine Regional Hospital Pardubice.

CASES

The caudal regression syndrome (CRS) was revealed in two women with praegestational diabetes. The diagnosis was made at 18 and 20 weeks. The characteristic ultrasound findings include abrupt interruption of the spine and abnormal position of the lower limbs. The femur bones are fixed in a "V" pattern, giving a typical "Buddha's poise". A complete examination must be conducted for possible urinary and intestinal malformations. The mechanism leading to malformation is discussed in the article. To prevent pregnancy at the time of bad controlled diabetes is the only way to minimaze the risk of producing a congenitally malformed baby including caudal regression syndrom in the population of diabetic mothers. Family planning and supervision by the specialists is always advisable.

CONCLUSION

Early diagnosis of CRS is possible using vaginal ultrasound. Emphasis is placed on the association of abrupt disruption of dorsal or lumbar spine and abnormal images of the lower limbs fixed in a,,V" formation, which is characteristic sign of CRS.

TRANSIENT SYRINGOMYELIA LEADING TO ACUTE NEUROLOGICAL DETERIORATION AFTER REPAIR OF A LIPOMYELOMENINGOCELE

OBJECTIVE

Transient paraplegia in the immediate postoperative period after lipomyelomeningocele repair is uncommon and is not discussed in the literature. We present the unique case of a patient who developed transient paraplegia 48 hours after lipomyelomeningocele repair attributable to the acute development of a thoracic syrinx.

CLINICAL PRESENTATIOn

At birth, the patient was noted to have a large skin-covered mass in the lumbosacral region. On neurological examination, both iliopsoas and quadriceps exhibited 3/5 motor function, and the plantar flexors and dorsiflexors exhibited 1/5 motor function. Urodynamic studies were normal. Magnetic resonance imaging demonstrated the presence of a lipomyelomeningocele associated with tethering of the spinal cord in the lumbosacral region.

INTERVENTION

At 5 months of age, the patient underwent repair of the lipomyelomeningocele. After surgery, the patient developed progressive paraplegia along with bowel and bladder dysfunction. Given the concern about a postoperative hematoma resulting in cauda equina syndrome, the patient returned to the operating room for a wound exploration. No compressive lesion such as a hematoma was found at surgery. A postoperative magnetic resonance imaging scan obtained afterward, however, demonstrated the presence of a large thoracic syrinx.

CONCLUSION

Syrinx formation can occur as early as 48 hours after lipomyelomeningocele repair, leading to progressive lower extremity weakness and bowel and bladder incontinence. In the immediate postoperative period, an acute syrinx can mimic cauda equina syndrome, and a magnetic resonance imaging scan is necessary to distinguish between these two entities. In this patient, the syrinx was transient and resolved without a shunting procedure.

Lumbosacral transitional vertebrae: incidence in a consecutive patient series

BACKGROUND

Great variability exists in the reported frequency of transitional vertebra in the general population as well as in symptomatic lumbar spine patients.

OBJECTIVE

To determine the occurrence rate of transitional vertebra in consecutive lumbar spine patients in our practice.

DESIGN

A prospective, observational study

METHODS

Plain films were viewed and the presence or absence of a lumbar transitional vertebra was documented. Transitional vertebrae were classified as incomplete or complete.

RESULTS

Of the 300 consecutive patients, 30% had a transitional vertebra.

CONCLUSION

Our percentage of patients with a transitional vertebra was higher than the percentages reported for the general population. This supports our belief that the alteration in mechanics caused by a transitional vertebra may at times contribute to pain generation. Additionally, as a transitional segment may not always be visualized on MRI, obtaining plain films prior to an injection or surgery will help prevent confusion over the appropriate level for the procedure.

Giant terminal lipomyelocystocele

Terminal myelocystocele is a rare form of occult spinal dysraphism in which the hydromyelic caudal spinal cord and the subarachnoid space are herniated through a posterior spina bifida. A 1-year-old female child presented with a large lumbosacral mass (30 x 20 x 10 cm), flaccid paraplegia and urinary incontinence since birth. Magnetic resonance imaging revealed a low-lying conus (with associated conus lipoma) and a dilated central canal surrounded by a meningocele suggestive of terminal lipomyelocystocele and was operated on successfully. In our experience, this was a giant terminal lipomyelocystocele and such a large lesion has not been reported in the literature before. Terminal myelocystocele should be included in the differential diagnosis of congenital lesions presenting as a lumbosacral mass and operated early.

Skeletal defects in ringelschwanz mutant mice reveal that Lrp6 is required for proper somitogenesis and osteogenesis

Here, we present evidence that Lrp6, a coreceptor for Wnt ligands, is required for the normal formation of somites and bones. By positional cloning, we demonstrate that a novel spontaneous mutation ringelschwanz (rs) in the mouse is caused by a point mutation in Lrp6, leading to an amino acid substitution of tryptophan for the evolutionarily conserved residue arginine at codon 886 (R886W). We show that rs is a hypomorphic Lrp6 allele by a genetic complementation test with Lrp6-null mice, and that the mutated protein cannot efficiently transduce signals through the Wnt/beta-catenin pathway. Homozygous rs mice, many of which are remarkably viable, exhibit a combination of multiple Wnt-deficient phenotypes, including dysmorphologies of the axial skeleton, digits and the neural tube. The establishment of the anteroposterior somite compartments, the epithelialization of nascent somites, and the formation of segment borders are disturbed in rs mutants, leading to a characteristic form of vertebral malformations, similar to dysmorphologies in individuals suffering from spondylocostal dysostosis. Marker expression study suggests that Lrp6 is required for the crosstalk between the Wnt and notch-delta signaling pathways during somitogenesis. Furthermore, the Lrp6 dysfunction in rs leads to delayed ossification at birth and to a low bone mass phenotype in adults. Together, we propose that Lrp6 is one of the key genetic components for the pathogenesis of vertebral segmentation defects and of osteoporosis in humans.

Lumbosacral transitional vertebral articulation: evaluation by planar and SPECT bone scintigraphy

It has been suggested that low back pain (LBP) may arise from lumbosacral transitional vertebral articulation (LSTVA) itself. It is known that bone scintigraphy is a valuable tool for the recognition of pain arising from bone and articular diseases. Therefore we aimed to show planar and SPECT bone scintigraphic findings of LSTVA and compare them with the LBP and X-ray findings. Twenty-eight patients (aged 20-63 years) in whom LSTVA had been identified radiographically were evaluated with planar bone scintigraphy, utilizing 99mTc methylene diphosphonate; and single photon emission computed tomography (SPECT) bone scintigraphy. Eighteen patients had LBP whereas 10 had not. There were 25 type IIA, one type IIB and two type IIIA LSTV articulation. On planar images, normal or non-focal minimally increased uptake superimposed on the upper sacroiliac joint was seen in patients without degenerative changes regardless of LBP whereas SPECT showed non-focal mild increased uptake on the area medial to the upper sacroiliac joint. Planar scans showed normal to non-focal mild, and mild-to-moderately increased uptake whereas SPECT demonstrated focal mild-to-moderately and markedly increased uptake in patients with degenerative changes without LBP and with LBP, respectively. The X-ray results showed an association of LBP degenerative changes, and the SPECT results showed a focal, markedly increased, uptake. We conclude that this focal, markedly increased, uptake may show the metabolically active degenerative changes of LSTV articulation and may help to reveal the pain arising from LSTVA. Therefore we propose that bone scintigraphy may be considered for the evaluation of patients with LBP thought to arise from LSTV articulation.

Lumbosacral agenesis and anteroposterior split cord malformation in a patient with single central maxillary incisor: case report and review of the literature

We report an infant born with lumbosacral agenesis, a subcutaneous lumbosacral mass, and a solitary median maxillary incisor. Operatively, a lipomyelomeningocele was noted to extend from the dorsal hemicord of a split cord malformation. Genetically, the child was found to have a defect on chromosome 7q. To our knowledge, this is the first case report of a patient with the rare lumbosacral agenesis and solitary median maxillary incisor. Furthermore, to our understanding, this is only the fourth reported case of split cord malformation in which the hemicords are oriented in the sagittal plane and one of only a few cases reported in the medical literature of simultaneous occurrence of lumbosacral agenesis and occult spinal dysraphism, that is, split cord malformation and lipomyelomeningocele. Following a review of the medical literature, and considering that our patient did indeed have dysmorphology of chromosome 7q, we hypothesize that this single defect resulted in both cranial and caudal deformation, as exemplified by our patient. We review the medical literature for related case reports and potentially related chromosomal abnormalities and various teratogenic substances.

Chemically induced supernumerary lumbar ribs in CD-1 mice: Size distribution and dose response

Supernumerary ribs (SNR) of differing sizes are commonly observed in rodent developmental toxicity studies, and the significance of treatment-related increases in SNR in standard studies has been contentious. We induced dose-related increases in SNR in fetal CD-1 mice by treating on gestation days 7-8 with benomyl (BEN; 0, 75, 150 mg/kg/d), dinoseb (DIN; 0, 30, 50 mg/kg/d); 2-methoxyethanol (2-ME; 0, 75, 150 mg/kg/d), or valproic acid (VPA; 0, 125, 250 mg/kg/d). Incidences of SNR were 9.3-27.6% in controls and 19.3-84.4% in the high dosage groups. SNR length showed a bimodal distribution with peaks at 0.3-0.4 mm and 0.9-1.1 mm in both treated and control groups. Based on length distributions, we used an actual length of 0.6 mm to separate short (rudimentary) from long (extra) SNR. DIN, 2-ME, and VPA induced a dose-related increase of extra ribs, while the incidence of rudimentary ribs remained at control levels. There was no apparent correlation of the presence of either type of SNR in a fetus and the occurrence of other anomalies. These data support the idea that extra and rudimentary SNR may reflect separate developmental phenomena, and should be considered and reported separately in developmental toxicity studies for risk assessment.

Lumbosacral agenesis in a premature infant of a diabetic mother

We report a non-familial case of lumbosacral agenesis born to a type 1 diabetic mother who had hyperglycemia during pregnancy despite regular insulin therapy. The male baby was noted to have atrophy of pelvis, flattening of the buttocks, and deformity of the lower limbs at birth. Spinal X-ray film revealed total agenesis of lumbar, sacral, and caudal spines. Magnetic resonance image disclosed interruption of the spinal cord at the level of T12 and adhesion between the two malrotated kidneys. Peripheral blood cytogenetic study revealed a normal male karyotype. Recurrent episodes of respiratory distress and urinary tract infection had bothered the patient subsequently. It is suggested that lumbosacral agenesis, a severe congenital defect, might be one of the anomalies of diabetic embryopathy.

Skeletal scintigraphy of young patients with low-back pain and a lumbosacral transitional vertebra

Lumbosacral transitional vertebrae can alter the biomechanics of weight transfer at the affected spinal segment. Low-back pain may result. This study assessed what skeletal scintigraphy reveals about stress associated with a lumbosacral transitional vertebra in young patients with low-back pain.

METHODS

The study population included 48 patients (30 male, 18 female; age range, 6-19 y; mean age, 15.7 y) with low-back pain and a lumbosacral transitional vertebra. Skeletal scintigraphy was correlated with plain radiographs in all, CT in 12, and MRI in 11.

RESULTS

High uptake was shown at the articulation between the transverse process of a lumbosacral transitional vertebra and the sacrum in 39 (81%) of the patients. In 23 (59%) of the 39 patients with high uptake, this finding was shown only by SPECT. In 13 (81%) of the 16 for which the high uptake was shown by planar imaging, the anterior projection was more valuable than the posterior projection. In 9 (23%) of the 39 patients with high uptake at the transverse-sacral articulation, the lumbosacral transitional vertebra had not been noted in a radiographic report before skeletal scintigraphy but was identified through reevaluation or repetition of radiographs after skeletal scintigraphy. Radiographs showed sclerosis along the transverse-sacral articulation in only 8 (21%) of the 39 patients with high uptake. Findings indicating stress or motion at the joint were shown by CT in 6 (55%) of 11 and by MRI in 5 (63%) of 8 patients with high uptake at the transverse-sacral articulation who underwent these examinations.

CONCLUSION

Skeletal scintigraphy often indicates stress at the transverse-sacral articulation of young patients with low-back pain and a lumbosacral transitional vertebra. Showing evidence of stress is best accomplished using SPECT. Changes are usually not radiographically evident, but there is a trend for MRI and CT to show findings that imply stress or motion at the articulation. The unique ability of skeletal scintigraphy to provide this physiologic information supports its use in these patients.

Tumors and malformations of the caudal spinal axis

The early development of the neural tube has been well studied in animals and humans. After axial determinants have been accomplished the processes of primary and secondary neurulation take place. Successful completion results in a spinal cord that has arisen from primary neurulation and a lower sacro-coccygeal portion from secondary neurulation. The latter region is the site of numerous skin-covered clinical lesions, which include tumors and malformations. A listing of selected features in 764 cases of skin-covered sacrococcygeal lesions is presented. The manner in which these lesions arise and the potential for genetic factors being responsible is discussed.

Child with a tail

An interesting case of a child with a tail is reported. The child had a tail like structure in the back since birth, increasing with age. It was 20 cm. long, the longest tail so far described in the English literature. There was no functional complain. The result was excellent after excision as the problem was only cosmetic.

Embryonic hydromyelia: cystic dilatation of the lumbosacral neural tube in human embryos

In a large collection of human embryos (the Kyoto Collection of Human Embryos, Kyoto University), we encountered five cases with abnormal dilatation of the neural tube at the lumbosacral level. In these examples, the central canal was enlarged, and the roof plate of the neural tube was extremely thin and expanded. The mesenchymal tissue was scarce or lacking between the roof plate and the surface ectoderm. This type of anomaly was assumed to be formed after neural tube closure and may be an early form of spina bifida. In two of the cases, some abnormal cells were found ectopically between the thin roof plate and the surface ectoderm. Morphologically, these cells resembled those forming spinal ganglia and could be of the neural crest origin. Since neural crest cells are pluripotent and can differentiate into a variety of tissues, such ectopic cells might undergo abnormal differentiation into teratomatous tumors and/or lipomas, which are frequently associated with spina bifida. We also discuss the definition of spina bifida and the classification of neural tube defects from the embryological and pathogenic viewpoints and propose a new classification of neural tube defects.

Extreme caudal agenesis. Possible drug-related etiology?

BACKGROUND

Caudal regression syndrome (CRS) is a rare anomaly of the lower body pole that represents a continuum of congenital malformations ranging from isolated sacral agenesis to absence of the lumbosacral spine and major visceral anomalies. While the exact etiology of this syndrome is unclear, maternal diabetes, genetic factors, teratogens and vascular anomalies altering blood flow have been hypothesized to play a role in its pathogenesis.

CASE

A fetus had extreme hypotrophy of the caudal body pole, aplasia of the lower spine and complete renal agenesis diagnosed in the second trimester by ultrasound. Maternal history revealed the use of minoxidil solution for preventing hair loss for four years prior to and during gestation. Also, the mother had taken trimethoprim-sulfamethoxazole during the first trimester for treatment of upper respiratory disease. No maternal diabetes or history of familial genetic diseases was evident.

CONCLUSION

In an extreme form of CRS consisting of complete aplasia of the lower body pole and viscera and additional malformations, a possible drug-related etiology was suggested but should be confirmed by more studies.

Dorsolumbosacral agenesis

Caudal regression is a rare congenital spinal anomaly characterized by partial or total agenesis of the sacral and/or lumbar spine. Sacral and/or lumbosacral agenesis has been well described. However, especially as far as MRI studies are concerned, thoracolumbosacral agenesis has rarely been reported.

Dermoid sinus at the lumbosacral junction in an English springer spaniel

A dermoid sinus was identified in a springer spaniel that presented with hindlimb neurological deficits. The sinus was continuous with the dura mater at the level of the lumbosacral junction. The presence of hair and debris adjacent to neural tissue had elicited a myelitis. A dorsal laminectomy was required to allow complete surgical resection of the sinus. The dog's neurological status improved after treatment and this improvement was maintained over a five-month follow-up period.

The lumbosacral lucent cleft

BACKGROUND

The lumbosacral lucent cleft was first described in association with traumatic injuries to the neck. However, we have observed this sign to be present in patients with no precursor of trauma, and we reviewed the incidence of lucent cleft sign in our local population and any characteristic features of the lucent cleft.

METHODS

Four-hundred and thirty lumbosacral spine radiographs were examined prospectively over an 8-month period, with correlation with clinical findings. Follow-up radiographs were obtained at 1, 3 and 6 months for patients with the lucent cleft sign.

FINDINGS

Nineteen patients (4.4%) were found to have lucent clefts in their lumbosacral spine X-rays. No significant change in the number and features to the lucent clefts was noted even when the symptoms had resolved after 6 months. All the lucent clefts were linear, horizontally oriented and located at the anterior edge of the adjacent vertebral body.

CONCLUSION

The lucent cleft sign in the spine, which has so far been described in association with has spinal trauma may be completely innocuous in patients with little or no symptoms.

Forebrain overgrowth (fog): a new mutation in the mouse affecting neural tube development

Forebrain overgrowth, fog, is a spontaneous autosomal recessive mutation in the mouse producing forebrain, lumbo-sacral, and facial defects. The defects appear to result from excessive growth or cellular proliferation leading to abnormalities in neural tube closure. Three unique features of the mutant are: (1) the growth of telencephalon cells into the surrounding mesenchyme, (2) presence of an encephalocele through the midline cleft in some mutants, and (3) dissociation of the tail defect from the caudal neural tube defect. We used an intersubspecific intercross between mice carrying the fog mutation and mice from an inbred Mus musculus castaneus strain (CAST/Ei) to map the fog mutation to mouse Chromosome 10 near D10Mit262 and D10Mit230 in a region with several potential candidate genes.

Abnormal anatomy of the lumbosacral region imaged by magnetic resonance in children with anorectal malformations

OBJECTIVE

To investigate the frequency of lumbosacral anomalies, the association with urogenital abnormalities, and the correlation with defaecation pattern by magnetic resonance imaging (MRI).

METHODS

A prospective analysis was performed of routine MRI in patients with anorectal malformations. Between 1990 and 1994, MRI was performed in 43 such patients: 31 boys and 12 girls. Twenty four had a high anorectal malformation, 16 had a low anorectal malformation, and three had Currarino's triad. MRI was performed before reconstruction in 26, and postoperatively in 17. Urogenital anomalies were found in 21.

RESULTS

Abnormalities of the spinal cord and spine were found with MRI in 20 patients (46.5%); caudal regression syndrome in 10, tethered cord in two, a combination of both in three, and other spinal anomalies in five. These anomalies were found in 30% of the patients with low anorectal malformations, and in 50% with high anorectal malformations. In patients with urogenital malformations, MRI more often showed spinal anomalies (13/21, 62%) than in patients without (7/22, 32%). In high anorectal malformations, defaecation was more often a problem in patients with spinal anomalies (12/15, 80%) than in patients without (2/8, 25%).

CONCLUSIONS

Spinal anomalies in the lumbosacral region were found with MRI in 46.5% of patients with anorectal malformations. Since presence of these anomalies seems to be related to clinical outcome, MRI should be performed routinely in all such patients.

Skeletal malformations caused by the Dh (Dominant hemimelia) gene in mice

Morphological characterization of the skeletal malformations caused by the Dh gene was carried out. Skeletal preparations from newborn mice of Dh/Dh, Dh/+ and +/+ genotypes, and adult Dh/+ mice were examined. The Dh gene induced skeletal deformities at the axial regions from the thorax to the tail. Attachment of the ribs to the sternum was sometimes irregular, and normal segmentation of the sternum was also disrupted. Abnormal fusion of the ventral part of the rib was observed in some cases. Lumbar vertebrae were fewer in number and abnormal in shape. Although it was rare, a curled tail was also observed due to distortion of the caudal vertebrae.

Radiographic and histological characterization of Tc/tw5 mice: an animal model of lumbosacral agenesis/myelomeningocele

Twenty-five Tc/tw5 and 12 control mice were killed at different ages and radiographically and histologically examined. In addition, histochemical analysis was performed on muscles from four mutant and one control mouse. All Tc/tw5 mice were tailless and had a fluid-filled lumbar myelomeningocele. Radiographically, most animals had six instead of 10 lumbosacral vertebrae. Vertebral anomalies were common. The spinal cord was grossly abnormal: at the level of the plaque, it was replaced by patches of neural tissue intermingled with connective tissue and muscle. Affected skeletal muscles had small myofibers with centrally placed nuclei consistent with arrest of development at the myotubular stage secondary to denervation in early embryonic life. Abnormal nerves were smaller and had fewer axons. Tc/tw5 mice show features of neural tube and notochord dysplasia. These mutant mice may be useful as animal models of lumbosacral agenesis and myelomeningocele.

Investigation of DNA synthesis in experimentally induced Long-Evans rat myeloschisis by the BrdU/antiBrdU technique

The volume and DNA synthesis of the neuroepithelium in induced myeloschisis in Long-Evans rats as shown by hematoxylin-eosin and BrdU/antiBrdU immunohistochemical staining patterns were examined at different stages of embryonal development. On day 14 of gestation, control animals contained BrdU-incorporating cells mainly at the alar plate of the closed neural tube. On the same day, the everted neural plate of rats with myeloschisis showed active, diffuse uptake of BrdU in the cells of the matrix layer, although an increase in the volume of the everted neural plate was not yet identifiable. On day 21 of gestation, rats with myeloschisis showed a marked increase in the volume of the neuroepithelium compared with controls. Our investigations suggest that, in myeloschisis, more neuroepithelial cells than normal retain their capability for DNA synthesis on day 14 of gestation, and the overgrowth of the neuroepithelium found on day 21 is possibly a secondary effect of failure of neural tube closure.

Human tail associated with lipomeningocele--case report

A 3-month-old boy presented with a tail associated with lipomeningocele. Computed tomography and magnetic resonance imaging clearly demonstrated the presence of spina bifida and lipoma continuous from the tail to the thickened conus medullaris. The human tail may be related to spinal dysraphism and requires detailed neuroimaging investigation, and possibly microsurgery to prevent the tethered cord syndrome.

Mental retardation, microbrachycephaly, hypotelorism, palpebral ptosis, thin/long face, cleft lip, and lumbosacral/pelvic anomalies

We describe 2 Brazilian sisters with a combination of clinical signs strongly suggesting a new autosomal recessive MCA/MR syndrome.

Spinal cord abnormalities in caudal regression syndrome

Caudal regression syndrome includes malformations ranging from mild forms of sacral agenesis to severe limb anomalies referred to as sirenomelia. The latter, in addition to sacral anomalies, shows malformed single lower limb and agenesis of rectum and genitourinary tracts. We report the neuropathologic examination in four infants, three with sirenomelia and one with lumbosacral agenesis. Brain and spinal cord were normal except for the structures in the caudal region of the spinal cord that were abnormal in all four cases. The first sirenomelic case with a mild sacral hypoplasia had only minor fusion of a few sacral roots and a slightly low-positioned conus medullaris. The second sirenomelic case with an intermediate degree of sacral hypoplasia had fusion of some of the sacral roots and ganglia, spinal ganglion cell heterotopias, filar lipoma and absence of the last sacral roots and ganglia. The third sirenomelic case with a severe degree of sacral hypoplasia showed additional tethering of the spinal cord. Case four with the agenesis of the lumbosacral spine had a total lack of the lumbosacral spinal cord, and dysplasia of the T11 and T12 cord segments. These findings suggest that the extent of anomalies of the caudal spinal cord structures in the caudal regression syndrome are roughly proportional to the anomalies of the vertebral column, and that they may constitute some of the main components of this syndrome.

Urological aspects of the tethered cord syndrome

We performed urological evaluations in 18 patients with the tethered spinal cord syndrome. Of the patients 4 had low grade vesicoureteral reflux but none had significant upper tract anomalies. Urodynamic studies documented a flaccid bladder in 9 patients (5 with supersensitivity to bethanechol), an uninhibited bladder in 5, mixed bladder dysfunction in 2 and normal function in 2. Repeat urodynamic studies were performed in 15 patients at least 6 months after release of the tethering. Of 8 patients with flaccid bladders studied postoperatively 6 had significant changes: 2 became normal, 2 had limited contractions and 2 had evidence of upper motor neuron abnormalities. Supersensitivity to bethanechol was of no predictive value. All 4 patients with uninhibited bladders who were evaluated preoperatively and postoperatively had improved and 3 currently are entirely normal. Careful urological evaluation of patients with the tethered spinal cord syndrome is helpful not only for diagnosis but also for appropriate management preoperatively and postoperatively. The fact that lower urinary tract function improves in some patients should encourage early and aggressive neurosurgical management of patients with this syndrome.

Multiple skeletal familial abnormalities associated with balanced reciprocal translocation 2;8(q32;p13)

A father and three of his offspring had skeletal abnormalities consisting of a short forearm, cubitus valgus, fusion of first and second cervical vertebrae, and cleft of L5 and S1. All four had a reciprocal, apparently balanced, translocation 2;8(q32;p13). Normal sibs had normal chromosomes. We conclude that this may be a rare instance of an autosomal dominant condition associated with a balanced chromosome translocation.

Neural tube development in mutant (curly tail) and normal mouse embryos: the timing of posterior neuropore closure in vivo and in vitro

A dye-injection technique has been used to determine the developmental stage at which posterior neuropore (PNP) closure occurs in normal and mutant curly tail mouse embryos. In vivo, the majority of non-mutant embryos undergo PNP closure between 30 and 34 somites whereas approximately 50% of all mutant embryos show delayed closure, and around 20% maintain an open PNP even at advanced stages of development. A similar result has been found for embryos developing in vitro from the headfold stage. Later in development, 50--60% of mutant embryos in vivo develop tail flexion defects, and 15--20% lumbosacral myeloschisis. This supports the view that delayed PNP closure is the main developmental lesion leading to the appearance of caudal neural tube defects in curly tail mice. The neural tube is closed in the region of tail flexion defects, but it is locally over-expanded and abnormal in position. The significance of these observations is discussed in relation to possible mechanisms of development of lumbosacral and caudal neural tube defects. This paper constitutes the first demonstration of the development of a genetically induced malformation in vitro.