Figure - available from: Pediatric Radiology
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Lipomyelomeningocele. a A longitudinal US image in a 1-day-old girl known from prenatal imaging to have a skin-covered neural tube defect shows a tethered cord (TC) terminating near the lumbosacral junction, interfacing (arrowhead) with a lipomatous mass (dashed arrow) that extends dorsal to the expected limit of the thecal sac. Fluid-filled meningeal tissue (solid arrows) also herniates into the lumbar soft tissue. b A sagittal T2-weighted MR image at 3 days old confirms a dysplastic tethered cord (solid arrow) contacting a lipomatous mass (dashed arrow) at the L5 level, with the interface extending beyond the dorsal limit of the thecal sac and continuing into the lumbar soft tissue, accompanied by fluid-filled meningeal tissue (asterisk). c An axial T2-weighted MR image shows dysplastic neural tissue (arrows) contacting skin-covered fat, with an interface between fat and neural tissue that extends from the canal to the posterior soft tissue. Fluid-filled meningeal tissue is visible (asterisk). d An axial T1-weighted MR image at the level of herniated tissue, showing that the interface (line) between the hyperintense fatty tissue and the dysplastic neural placode, extends from the canal to the posterior soft tissue. This case varies slightly from a pure lipomyelomeningocele in that the lipoma (in this case, a transitional lipoma thought to result from disordered neurulation near the junction of the neural tube and caudal cell mass) contacts the left side of the neural placode and is partially within the spinal canal, as opposed to a lipomatous mass that is entirely outside of the canal and along the dorsal aspect of the placode
Source publication
Ultrasonography (US) is the first-line imaging modality for screening neonates and young infants with suspected spinal abnormalities. Whether performed for a suspicious congenital skin lesion, such as a lumbosacral tract or lipomatous mass, or abnormal neurological findings, US can help define spinal anatomy, characterize congenital spine malformat...
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Key Clinical Message
Three‐dimensional transesophageal ultrasound of the spinal cord is a new and promising imaging modality that could easily be used clinically for real‐time evaluation of the spinal cord anatomy or for intraoperative guidance.
Citations
... It is important to determine the position of the conus medullaris relative to the spine by numbering the vertebrae. Counting up from the distal spine is the most common method [2]. The junction between the 5th lumbar (L5) and 1st sacral (S1) vertebrae typically features a change in angulation: the lumbar vertebrae are horizontally oriented, while the sacral vertebrae are lordotic [3] (Fig. 1). ...
... The normal position depends on the gestational age: between 14 and 18 weeks of gestational age (GA), the conus is at L4 or lower; and between 19 and 24 weeks of GA, it is at the L2-L3 level in 97% of normal fetuses [4]. At term gestational age, the conus normally ends at or above the L2-L3 level [2]. ...
Spinal dysraphisms are amenable to diagnosis in utero. The prognosis and the neonatal management of these conditions differ significantly depending on their types, mainly on the distinction between open and closed defects. A detailed evaluation not only of the fetal spine, but also of the brain, skull, and lower limbs is essential in allowing for the right diagnosis. In this article, recommendations from the Fetal Task Force of the European Society of Paediatric Radiology (ESPR) and the European Society of Neuroradiology (ESNR) Pediatric Neuroradiology Committee will be presented. The aim of this paper is to review the imaging features of the normal and abnormal fetal spinal cord, to clarify the prenatal classification of congenital spinal cord anomalies and to provide guidance in their reporting.
Graphical Abstract
... In pediatric populations, the posterior elements of the spine do not fuse until approximately six months of age, allowing ultrasound to be a useful first exam [13]. Sonographic evidence of a tethered cord includes caudal positioning of the conus medullaris below the L2/L3 vertebral level as well as reduced motion of the conus or cauda equina [14,15]. MRI can confirm the positioning of the conus [3]. ...
For infants presenting with urinary problems or lower extremity weakness, imaging is ordered to investigate spinal pathology. Tethered cord syndrome (TCS) often manifests without conclusive anatomic evidence. In our case, a premature infant presented with urosepsis and was found to have an asymmetric gluteal crease and a sacral dimple. Renal ultrasound showed mild hydronephrosis, and a cystourethrogram revealed bilateral high-grade vesicoureteral reflux. Ultrasound and magnetic resonance imaging demonstrated a borderline low-lying spinal cord at the mid-L3 vertebral level. Urodynamic testing to confirm neurogenic bladder could not be completed on the first attempt due to urinary tract infection and on the second attempt due to instrument intolerance. Despite the lack of conclusive imaging evidence of a tethered cord, enough supportive clinical data was present to proceed with surgical intervention with the goal of preventing the progression of neurological dysfunction. Because TCS is ultimately a clinical diagnosis, appropriate management should not be discouraged by inconclusive or borderline imaging findings.
... Because ultrasound is contraindicated for direct investigation of the open spinal defect, MRI is necessary to characterize the dysraphism as well as associated cerebral and cerebellar malformations. T2-weighted sequences are especially useful for demonstrating the expansion of the meningeal spaces [30]. ...
A broad spectrum of spinal pathologies can affect the pediatric population. Ultrasound (US) is the primary modality for pediatric spine assessment due to its widespread availability, non-requirement of sedation, and absence of ionizing radiation. Supplementing this, MRI offers an in-depth exploration of these conditions, aiding in preoperative strategizing. In this review, we examine the clinical indications, methodologies, and protocols for US and MRI scans of the pediatric spine. Additionally, we illustrate normal pediatric spinal anatomy, highlighting several examples of normal variants that are often misinterpreted. Through a series of case-based illustrations, we offer a comprehensive overview of various pathological conditions such as tethered cord, spinal dysraphism, spinal lipoma, diastematomyelia, and dermal sinus tract, among others. Furthermore, we explore the correlation between US and MRI findings for these lesions, employing real-world cases to enhance our understanding of this topic.
... Occasionally, ultrasound use leads to the incidental discovery of abnormalities in cranial structure, such as craniosynostosis and plagiocephaly [75][76][77] . Ultrasound technology is often used to characterize soft-tissue defects, lesions, and malformation pathologies of the spine, such as incomplete ossification seen in spina bifida [78][79][80] . To a lesser degree, ultrasound can be used in adults to visualize blood vessels of the neck and monitor blood flow in the brain and help identify potential stroke, brain tumors, hydrocephalus, and vascular issues. ...
Neurosurgery as a specialty has developed at a rapid pace as a result of the continual advancements in neuroimaging modalities. With more sophisticated imaging options available to the modern neurosurgeon, diagnoses become more accurate and at a faster rate, allowing for greater surgical planning and precision. Herein, the authors review the current heavily used imaging modalities within neurosurgery, weighing their strengths and weaknesses, and provide a look into new advances and imaging options within the field. Of the many imaging modalities currently available to the practicing neurosurgeon, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), and ultrasonography (US) are used most heavily within the field for appropriate diagnosis of neuropathologies in question. For each, their strengths are weighed regarding appropriate capabilities in accurate diagnosis of cranial or spinal lesions. Reasoning for choosing one over the other for various pathologies is also reviewed. Current limitations of each is also assessed, providing insight for possible improvement for each. New advancements in imaging options are subsequently reviewed for best uses within neurosurgery, including the new utilization of FIESTA sequencing, glymphatic mapping, black-blood MRI, and functional MRI. The specialty of neurosurgery will continue to heavily rely on improvements within imaging options available for improved diagnosis and greater surgical outcomes for the patients treated. The synthesis of techniques provided herein may provide meaningful guidance for neurosurgeons in effectively diagnosing neurological pathologies while also helping guide future efforts in neuroimaging developments.
Background
Spinal dysraphism (SD) encompasses congenital spinal defects that result from inappropriate fusion of the different midline osseous, mesenchymal, and neural elements. The primary tools for diagnosis of SD are both spinal ultrasonography (USG) and magnetic resonance imaging (MRI). Spinal USG is growingly being used as an initial screening modality with sensitivities and accuracies equivalent to those of MRI. Anorectal malformations (ARM) have ultimate association with many other congenital abnormalities, of which spinal dysraphism is one of the most common. The main aim of study was to assess the diagnostic accuracy of spinal USG as a screening modality in comparison with MRI in infants with closed spinal dysraphism. We also endeavored to highlight the associated spinal dysraphism radiological findings in patients with either ARM or back cutaneous stigmata.
Results
Our prospective diagnostic comparative study included 33 patients, all of whom underwent both MRI and USG. Both MRI and USG showed appreciable agreement in the assessment of spinal dysraphism. In comparison with the gold standard MRI, spinal USG revealed comparable diagnostic metrics: specificity (98.6–100%), sensitivity (66.6–91.6%), PPV (90–100%) and NPV (94.1–98.7%) in diagnosis of different types of spinal dysraphism. The main clinical presentation of nineteen patients was anorectal malformation (ARM), 11 of whom (57.9%) had evidence of associated spinal dysraphism. The most common types of ARM were cloacal malformation, recto-urethral fistula, and rectal atresia with no fistula. On the other hand, sixteen patients were mainly presented with back cutaneous stigmata, 11 of whom (68.8%) had associated spinal dysraphism. The most common presenting cutaneous stigmata were low back swelling and atypical dimples.
Conclusion
The front-line screening modality for infants with closed SD should be spinal USG, however, its main limitation is the restrained time window in the first 6 months of life. Infants with ARM should be screened for spinal anomalies, especially those with high and complex types. Infants with high-risk back cutaneous stigmata should be similarly screened, as well.
