Ultrasound Shows Something Weird in the Baby Heart
Ultrasound of the Neonatal spine
Erik Beek and Simone ter Horst and Robin Smithuis and Rutger Jan Nievelstein
Department of Radiology of the Wilhelmina Childrens Hospital, University Medical Center Utrecht and the Alrijne hospital in Leiderdorp, the Netherlands
Publicationdate
Ultrasound is the preferred modality in neonates with suspected occult spinal dysraphism (OSD).
OSD implies the presence of one or more than spinal cord anomalies, which tin can cause tethering of the spinal string and possible neurological and float or bowel function deficits.
Ultrasound is easy to perform, since the posterior arch of the vertebra is not yet ossified, providing a perfect audio-visual window.
Especially the lumbosacral part of the spinal culvert with the conus medullaris and the cauda equina tin can be beautifully depicted with a high resolution linear assortment probe.
Classification of Spinal dysraphism
Spina bifida aperta
Spinal dysraphism or spina bifida is a congenital anomaly resulting in a defective closure of the neural curvation.
Information technology is classified into open (spina bifida aperta) and airtight dysraphism (spina bifida occulta).
Open dysraphism presents with a swelling over the back which is noticed at birth and may contain meninges and CSF, called meningocele or contain parts of the spinal string or nerves, called myelomeningocele.
Ultrasound should not be used to image open up spinal dysraphism at the lesion itself.
It does not add much and tin can lead to infection.
Ultrasound can be used to examine more cranial parts of the vertebral column, searching for additional anomalies and is useful to measure out the size of the ventricles of the encephalon after closure of the myelomeningocele.
Spina bifida occulta
In closed or occult spinal dysraphism, likewise called spina bifida occulta, at that place is an intact covering of the skin.
The anomaly is suspected when there are peel changes like hair tufts, hemangiomas, pigmented spots, cutaneous dimples or a subcutaneous mass.
Another reason to perform ultrasound is when at that place is a congenital bibelot that is associated with OSD similar anal atresia.
The term OSD implies the presence of i or more spinal cord anomalies, which can crusade tethering of the spinal string and possible neurological and bladder/bowel function deficits.
The terms thickened or fatty filum terminale, spinal lipomas, split cord malformations, dermoid cyst, and syringohydromyelia are all different forms of OSD.
Normal anatomy
Click to overstate
The spinal string is depicted as a very hypoechoic structure with a central echogenicity.
This primal echogenicity is supposed to represent the interface betwixt the inductive commissure and the median anterior fissure, and not the cardinal canal.
Axial image of the spinal cord with central echogenicity.
Centric image of the cauda equina.
The lower cease of the cord is thickened, which is the lumbar intumescence.
The cord tapers in a precipitous cone (bluish pointer).
The cauda equina is seen every bit a agglomeration of moving strands.
If the baby is lying in the decubitus position, the strands will gravitate to the dependent posterior side.
If the infant is examined in the prone position with a pillow under the abdomen, the stands volition motion ventrally.
The filum terminale tin can be seen as a sparse echogenic thread.
The dural sac ends at approximately S2.
More than distally fatty tissue is present.
Video of the normal sagittal anatomy.
Always obtain centric views.
The move of the nervus roots is improve seen in the transverse airplane compared to the sagittal plane and it is easier to assess intraspinal pathology like a thickened filum.
Film in right decubitus position.
The nerve roots are clustered in the dependent side, merely move freely.
When the nerve roots do not motion freely, it can be a sign of OSD.
Position of the conus medullaris
The normal position of the conus is at L!.
Information technology should not be beneath L2.
The all-time style to make up one's mind the position of the conus medullaris is by identifying the lumbosacral junction at the lordotic bending between the lumbar and sacral vertebrae (arrow).
It can be helpful to flex and extend the pelvis to see the bespeak of motion of the sacrum.
In this newborn the lumbosacral junction is less clearly seen considering there is no acute angle.
The numbers that we've put in, might be wrong.
If i is uncertain, make a panoramic or dual image of the lumbosacral vertebral column and compare the vertebral count from below upwardly with a lateral plainly film.
Sagittal view of a normal "kyphotic" coccyx in a ii-day-old girl
The coccyx, if not nonetheless ossified, is equanimous of hypoechoic cartilage.
It ordinarily has a kyphotic shape.
On transverse views information technology should not be confused with a fluid collection or an abscess.
Normal variants
Two-week-old girl with a sacral elementary. There is a slight hydromyelia (white arrow) and a cyst in the filum terminale (yellow pointer), both are normal variants.
Central canal
In this image the central canal is visible as a thin anechoic line in the spinal cord (white arrow).
Although this is sometimes associated with pathology it is frequently seen as a normal finding.
Ventriculus terminalis
A modest cyst is seen in the proximal filum terminale.
This is called a ventriculus terminalis (or fifth ventricle).
Sometimes it is seen in the conus medullaris.
Information technology is formed during embryogenesis and usually regresses completely during early childhood.
If information technology stays persistent, information technology typically measures less than 2 cm in craniocaudal dimension and 2 mm in transverse dimension and is detected as an asymptomatic and incidental finding in adults.
Here a sagittal epitome of a three-months-former girl who was imaged because of a pare discoloration of the lower back.
The spinal anatomy was normal and there was no sign of OSD.
At that place is a straight coccyx, which is a normal variant.
Unremarkably the coccyx has a anteriorly bent tip, merely sometimes information technology is straight or fifty-fifty dorsally aptitude, which is also a normal variant.
Pathology
Tethered cord
In many cases occult spinal dysraphism may non cause whatever symptoms.
Nevertheless in some cases there may develop neurological problems due to tethering of the cord.
A tethered cord is a pathologic fixation of the spinal cord in an abnormal caudal location, so that the string suffers mechanical stretching, distortion and ischemia with growth and development.
In these cases ultrasound is well suited to epitome the contents of the spinal canal and to wait for findings that are associated with a tethered string (Table).
Low conus medullaris
Newborn girl with a cloacal malformation.
The conus medullaris is at L5.
No lipoma visible.
Findings were confirmed at MR imaging which was acquired at the age of 9 months.
Continue with the MR.
MR image at the age of 9 months.
The conus medullaris is now seen at L4.
Thickened filum terminale
Report the image.
What are the findings?
Findings:
The plain film shows a fusion of S4 and S5.
This was a newborn male child with an anorectal malformation.
An ultrasound was performed to expect for signs of occult spinal dysraphism.
This is the transverse video
There is a thickened filum with a depression ending conus medullaris at L3-L4 and a balmy hydromyelia.
Continue with the sagittal video.
On the sagittal video the low ending conus medullaris is seen at L3-L4.
Continue with the MRI.
The MRI also depicts:
- Hydromyelia
- Low ending conus medullaris.
- Thickened filum terminale
The upper limit of normal for the width of the filum terminale is 2 mm.
If it is thickened it often shows fatty infiltration with hyperechoic tissue.
In healthy newborns, the tip of the conus medullaris is located between L1 and L2.
The tip should not exist positioned below L2-3.
Hydromyelia
A hydromyelia is the abnormal widening of the central canal by cerebrospinal fluid. This condition may be either focal or lengthened, extending through the entire length of the spinal string.
It tin be associated with several congenital abnormalities including diastematomyelia, Arnold‐Chiari malformation, myelomeningocele and lipomeningocele.
If there is a fluid drove in the string outside the central canal it is chosen syringomyelia.
Considering it is often not possible to separate these ii entities on imaging, it is better to use the term syringohydromyelia.
Transverse images will show the transition of the normal string into the string which surrounds a CSF collection
Spinal lipoma
A spinal lipoma is an encapsulated deposit of fatty, neural tissue, meninges or fibrous tissue which extends from the posterior subcutaneous tissue through a midline defect of the fascia, muscle or bone to communicate with the spinal canal or meninges.
A spinal lipoma is seen as an echogenic mass, mostly in the lower spinal culvert.
The conus tin be too low and buried in the lipoma.
Here a sagittal prototype of a newborn boy with anal atresia.
The conus is blunted and ends at L2-L3.
At that place is an echogenic mass which is likely a lipoma.
The filum is thickened.
Pocket-size lipomas are often led alone. Bigger lipomas in symptomatic patients are removed.
On a transverse video the ecogenic mass but below the string terminus is seen.
Dorsal dermal sinus
This is a connection between the skin and the dural sac, sometimes into the spinal cord.
Information technology presents with a dimple, discoloration of the skin or hairy patches.
The conus medullaris can exist also depression.
Three-day-erstwhile daughter with a red stain on the lower back, a tuft of pilus and a dimple.
US shows a tract from the skin towards the dural sac at the S1-S2 level, compatible with a dorsal dermal sinus .
The conus medullaris is at a normal level and there is no other intraspinal pathology present.
A T1-weigthed image shows the sinus tract from the skin towards the S1-S2 level.
The conus medullaris is too depression at L3-L4.
Dermal sinus tracts are particularly of import lesions to recognize because they can extend to the spinal culvert and correspond an increased chance of infection such as meningitis and spinal cord abscess.
Diastematomyelia
Diastematomyelia, as well named carve up string malformation, is a longitudinal split of the spinal cord.
At the betoken of division, in that location may be an osseous, fibrous or cartilaginous dividing septum.
Diastematomyelia is commonly associated with a vertebral column aberration and a tethered spinal cord.
The ultrasound diagnosis is usually straightforward.
Here images of a newborn, who had several antenatal anomalies.
In that location was a lateral rocker bottom anxiety deformity, lumbar kyphoscoliosis and swelling on the lower back.
The spinal U.s. and MR bear witness a longitudinal divide of the spinal cord at the thoracolumbar level.
The bifid cord is disproportionate in volume.
Additional plain films of the lumbar spine and pelvis showed thoracic and lumbar hemivertebrae.
There was as well a dislocated left hip.
Newborn girl with an anorectal malformation. The distal sacrum below S4 is absent-minded.
Edgeless cord terminus
This image is of a newborn girl with an anorectal malformation.
The distal sacrum beneath S4 is absent (arrow).
Since an anorectal malformation is oft associated with spinal pathology, an ultrasound was performed.
If a plain film of the vertebral cavalcade demonstrates an anomaly of the sacrum, there is a 50% change of an intraspinal anomaly.
In most cases there is a low ending tethered cord.
In some cases however the cord ends at the normal position, simply is deformed.
This is a so-chosen edgeless string terminus.
There is generally a wedge-shaped catastrophe in which the dorsal side reaches further caudally than the ventral side.
Continue with the ultrasound.
Ultrasound of the spine shows a blunt cord terminus at T12-L1.
A edgeless cord terminus is a sign of caudal regression syndrome characterized by abnormal development of the lower end of the spine.
On ultrasound the absent coccyx is also visible.
Continue with the MRI.
Sagittal T2-weigthed image showing the cord terminus at Th12.
Ultrasound Shows Something Weird in the Baby Heart
Source: https://radiologyassistant.nl/pediatrics/spine/ultrasound-of-the-neonatal-spine
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