Pediatric Spinal Canal Michael DiPietro, MD
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1 Pediatric Spinal Canal Michael DiPietro, MD John F Holt Collegiate Professor of Radiology University of Michigan Ann Arbor, MI USA MSUS #22 19 Sept. 2012
2 Objectives for Learners - spine Identify normal conus, cauda equina Know technique Know what looking for with closed occult dysraphism Know some forms of occult dysraphism Recognize caudal regression, sacrococcygeal mass (teratoma).
3 Vertebral anomaly
4 Pediatric Spine Sonography actually spinal canal sonography (spinal canal contents)
5 Two back masses Patient #1 Dermatofibrosarcoma protuberans Patient #2 Schwannoma
6 Does a back mass involve the spinal canal?
7 Successful Pediatric Spinal Canal Ultrasound Orientation Orientation Orientation Orientation Technique Technique Technique Technique
8 Pediatric Spine Sonography 28 years personal experience Pediatric Neurosurgeon
9 Normal Anatomy
10 Normal neonate & young infant exquisite panoramic detail EFOV image Courtesy of S. O Hara, MD
11 Neonate & young Infant exquisite panoramic detail combined image mdip
12 Locate conus medullaris tip 2 views TR Sag
13 Thoraco Lumbar Lumbo sacral L low L
14 Conus tip
15 Lumbo - sacral
16 Long Axis Sagittal Find sacrum and coccyx Adjust depth Ascend to and above lumbar.. As shown next
17 Sacrum Coccyx
18 Lumbosacral Junction
19 Mid to Low Lumbar
20 High Lumbar
21 Pediatric Spinal Canal Ultrasound Transducers - appropriate high frequency, high resolution extended field of view dynamic cine loop storage
22 Successful Spine Ultrasound Technique Technique Technique especially adequate flexion to separate posterior elements
23 Scenarios Skin covered defect with dorsal bulge Occult tethered spinal cord cutaneous marker (next slide) anal atresia (imperforate anus) lipoma Caudal regression SC teratoma
24 Neonatal - Occult tethered cord Cutaneous markers The Dimple Hemangioma Hair tuft Fatty hump Aplasia cutis
25 Why Spinal Canal US?? Most requests are to r/o occult tethered spinal cord
26 Definition Tethered Cord a pathologic fixation of the spinal cord in an abnormal caudal location, so that the cord suffers mechanical stretching, distortion, and ischemia with daily activities, growth and development D.H. Reigel, M.D. Pediatric Neurosurgeon Pittsburgh, PA
27 Tethered cord low down, stuck up Stuck up Low down
28 Occult tethered spinal cord tethered cord low down stuck up low (caudal) eccentric (often dorsal) tethering lesion (e.g. lipoma, thick filum, fibrolipoma) damped caudal oscillations
29 Cord oscillation cine M mode (Europe) Sag Sag
30 Cord oscillation cine M mode TR
31 Occult tethered cord Cutaneous markers The Dimple Hemangioma Hair tuft Fatty hump Aplasia cutis
32 Scenarios Skin covered defect with dorsal bulge Occult tethered spinal cord anal atresia lipoma Caudal regression SC teratoma
33 Teth. Cord Lipoma US MRI Correlate
34 Teth. Cord Lipoma US MRI Correlate
35 Scenarios Skin covered defect with dorsal bulge Occult tethered spinal cord anal atresia lipoma Caudal regression SC teratoma
36 Neonate VACTERL Anal atresia Low conus Thick echogenic filum terminale
37 Scenarios Skin covered defect with dorsal bulge Occult tethered spinal cord anal atresia lipoma Caudal regression SC teratoma
38 Sacral issues Hypoplastic or absent - conus shape Crescentic presacral Currarino Triad Vertebral anomaly
39 Newborn girl.
40 Posterior Prone - Lumbar Typical Appearance
41 Posterior Prone Lumbar Normal Abnormal NL conus Blunt or wedge conus
42 What might mom have?? Diabetes mellitus
43 Caudal regression syndrome Blunt or wedge shaped conus Here terminates above L1. Thick caudal FT ( ) Abnormal sacrum
44 Also has thick caudal filum terminale (FT not always thick)
45 Scenarios Skin covered defect with dorsal bulge Occult tethered spinal cord anal atresia lipoma Caudal regression SC teratoma
46 Interesting Case US only Case to OR Bypassed MRI All roads don t lead to Rome. All US studies don t lead to MRI.
47
48 Fetal MRI
49 Day 2
50 Initial Pelvic US Anterior via Bladder Sup Inf BL UT S S S R S
51 Post natal MRI Protocol MRI was ordered Spine study? Pelvis study?
52 Post natal MRI Protocol MRI was ordered Spine study? Pelvis study? We suggested Try US to sort the issues and plan the MRI
53 Post natal MRI Protocol Try Posterior US Might not need MRI At least better prescribe MRI protocol
54 Posterior US r/o Tethered Cord
55
56
57
58
59
60 Not cephalad to S5
61
62 Left TR - Posterior Right
63
64 Reviewed US with Surgeon Stressed clarity of images Logical approach Surgeon canceled MRI To OR Pathology = mature teratoma
65 Pathology Mature Teratoma
66 Another Case 9 month old female with hypoplastic sacrum.
67 Lumbosacral Junction Prone Sagittal
68 Lumbosacral Junction Cine transverse
69 Low lying tethered cord attached to a lipoma of the filum terminale continuous with a presacral mass. 9 mo old US diagnostic but anatomy not as clear as prior case get MRI Lumbosacral junction Prone Sagittal
70 T2 WI T1WI
71 ISSUES
72 Issues Cutaneous stigma Conus level Filum terminale thick, cyst Skin covered dysraphism (occulta) Skin open dysraphism (aperta) Pre-natal to post-natal Imperforate anus; VACTERL Abnormal sacrum (crescent; absent) Age (size) limit
73 Issues Cutaneous stigma Conus level Filum terminale thick, cyst Skin covered dysraphism (occulta) Skin open dysraphism (aperta) Pre-natal to post-natal Imperforate anus; VACTERL Abnormal sacrum (crescent; absent) Age (size) limit
74 Issues Cutaneous stigma Conus level Filum terminale thick, cyst Skin covered dysraphism (occulta) Skin open dysraphism (aperta) Pre-natal to post-natal Imperforate anus; VACTERL Abnormal sacrum (crescent; absent) Age (size) limit
75 Issue Age Limit? Age limit (i.e. size limit)? Techniques for older infant or child Who orders for older? Just get MRI for all ages? Spatial resolution neonatal US (0.01cm = 100 microns) Just get MRI older?
76 Older Child occult tethered spinal cord as older and larger visualization is limited off midline interlaminar window might locate conus tip and note +/- oscillation *be sure you and clinician know limits if need more information get MRI!!
77 Off midline
78 8 years normal conus tip position Oscillation +/- Conus tip if need more information get MRI
79 Cauda equina 9 yo 65 lb Angled from left Midline Angled from RT TR
80 Vertebra
81 Case 17-day-old girl who has bilateral equinovarus feet and kyphoscoliosis
82 Where is the spinal cord??
83 Prone Sagittal
84 L3 kyphoscoliosis, and dermal sinus tract with intradural lipoma (*), and tethered spinal cord * L3 L5
85
86 New case Neonate with esophageal atresia and TE fistula Multiple Vertebral Anomalies
87
88 Sup More lateral More midline
89
90
91 Short coccyx
92 Same case Neonate with esophageal atresia and TE fistula Multiple Vertebral Anomalies Spinal Cord and Filum Terminale
93 A B C
94 A B C
95 * * Likely ASA and spinal cord
96 Topics Covered Identify normal conus, cauda equina Know technique Know what looking for with closed occult dysraphism Know some forms of occult dysraphism Recognize caudal regression, sacrococcygeal mass (teratoma).
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