Surgery for spina bifida occulta: spinal lipoma and tethered spinal cord.

The technical evolution of the surgery for spina bifida occulta (SBO) over the course of a half-century was reviewed with special foci placed on the spinal lipoma and tethered spinal cord. Looking back through history, SBO had been included in spina bifida (SB). Since the first surgery for spinal lipoma in the mid-nineteenth century, SBO has come to be recognized as an independent pathology in the early twentieth century. A half-century ago, the only option available for SB diagnosis was the plain X-ray, and pioneers of the time persevered in the field of surgery. The classification of spinal lipoma was first described in the early 1970s, and the concept of tethered spinal cord (TSC) was proposed in 1976. Surgical management of spinal lipoma with partial resection was the most widely practiced approach and was indicated only for symptomatic patients. After understanding TSC and tethered cord syndrome (TCS), more aggressive approaches became preferred. A PubMed search suggested that there was a dramatic increase of publications on the topic beginning around 1980. There have been immense academic achievements and technical evolutions since then. From the authors' viewpoint, landmark achievements in this field are listed as follows: (1) establishment of the concept of TSC and the understanding of TCS; (2) unraveling the process of secondary and junctional neurulation; (3) introduction of modern intraoperative neurophysiological mapping and monitoring (IONM) for surgery of spinal lipomas, especially the introduction of bulbocavernosus reflex (BCR) monitoring; (4) introduction of radical resection as a surgical technique; and (5) proposal of a new classification system of spinal lipomas based on embryonic stage. Understanding the embryonic background seems critical because different embryonic stages bring different clinical features and of course different spinal lipomas. Surgical indications and selection of surgical technique should be judged based on the background embryonic stage of the spinal lipoma. As time flows forward, technology continues to advance. Further accumulation of clinical experience and research will open the new horizon in the management of spinal lipomas and other SBO in the next half-century.

Epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis: a single-institution experience in Japan.

BACKGROUND: Lumbar spondylolysis, a common identifiable cause of low back pain in young athletes, reportedly has a higher incidence rate in males. However, the reason for its higher incidence in males is not clear. This study aimed to investigate the epidemiological differences between the sexes in adolescent patients with lumbar spondylolysis. METHODS: A retrospective study was conducted in 197 males and 64 females diagnosed with lumbar spondylolysis. These patients visited our institution from April 2014 to March 2020 with their main complaint being low back pain, and they were followed-up until the end of their treatment. We investigated associations between lumbar spondylosis, their background factors, and characteristics of the lesions and analyzed their treatment results. RESULTS: Males had a higher prevalence of spina bifida occulta (SBO) (p = 0.0026), more lesions with bone marrow edema (p = 0.0097), and more lesions in the L5 vertebrae (p = 0.021) than females. The popular sports disciplines were baseball, soccer, and track and field in males, and volleyball, basketball, softball in females. The dropout rate, age at diagnosis, bone union rate, and treatment period did not differ between the sexes. CONCLUSION: Lumbar spondylolysis was more common in males than in females. SBO, bone marrow edema, and L5 lesions were more frequent in males, and sports discipline varied between the sexes.

Association of spinal anomalies with spondylolysis and spina bifida occulta.

PURPOSE: To investigate the association of spinal anomalies with lumbar spondylolysis and spina bifida occulta (SBO). METHODS: A total of 1190 patients with thoracic, abdominal, and pelvic computed tomography scans available were categorized according to the number of presacral (thoracic and lumbar) mobile vertebrae and the presence or absence of lumbosacral transitional vertebrae (LSTV). The prevalence of spondylolysis and SBO and the association of spinal anomalies with these disorders were evaluated. RESULTS: Normal morphology (17 mobile vertebra with no LSTV) was found in 607 men (86.5%) and 419 women (85.9%) and about 14% of patients had anomalies. Spondylolysis was found in 74 patients (6.2%), comprising 54 men (7.7%) and 20 women (4.1%). SBO involving the lumbar spine was found in 9 men (1.3%) and 2 women (0.4%). Spondylolysis was significantly more common in men with 18 vertebrae without LSTV (21.1%) than in those with 17 vertebrae without LSTV (7.2%) (p = 0.002). The prevalence of spinal anomalies was 55.6% in men and 50.0% in women with SBO that included a lumbar level was significantly higher than in both men (13.5%, p < 0.001) and women (4.8%, p = 0.003) without SBO. CONCLUSION: These findings indicate that there is a relationship between spinal anomalies and both spondylolysis and SBO, which may lead to elucidation of the mechanism of onset of spondylolysis and improve its treatment and prognosis. Awareness that patients with SBO involving the lumbar spine have an increased likelihood of a spinal anomaly may help to prevent level errors during spinal surgery.

Sagittal spinopelvic alignment in tethered cord syndrome and split cord malformation.

PURPOSE: Sagittal imbalance is common in degenerative and congenital spinal diseases. Some studies have examined spinal deformities in the spina bifida. However, sagittal spinopelvic parameters in tethered cord syndrome (TCS) and split cord malformation (SCM) have been poorly evaluated in the literature. In this study, we investigated sagittal spinopelvic differences in TCS due to fatty filum terminale and SCM patients. MATERIAL AND METHODS: A total of 78 patients with spina bifida occulta (30 SCM and 48 TCS due to fatty filum terminale) were included in the study. Radiological images of these patients were retrospectively evaluated. We evaluated the pelvic incidence, pelvic tilt, sacral slope, sagittal vertical axis (SVA), T1 pelvic angle, lumbar lordosis (LL), thoracic kyphosis, thoracolumbar alignment, and change in those parameters with age. RESULTS: Correlation coefficients between age and LL, T1 pelvic angle, and the SVA in patients with TCS due to fatty filum terminale were statistically significant. In addition, correlation coefficients between age and LL and the SVA in patients with SCM were statistically significant. Notably, LL was increased at a statistically significant level with age in patients with TCS and SCM. CONCLUSION: Improved knowledge of spinal balance parameters in patients with TCS and SCM may be helpful in understanding the clinical course of these pathologies, and provide information regarding the success of surgery at the follow-up period.

Co-existence of spina bifida occulta and lumbosacral transitional vertebra in patients presenting with lower back pain.

Lower back pain is a common symptom, which is managed by various specialties including neurology, orthopedics, general medicine, and rheumatology. Lumbosacral transitional vertebra (LSTV) is an important cause of back pain, about which many clinicians are unfamiliar. It is a congenital malformation of the spine, which results from abnormal fusion of the sacrum with the vertebra above, to a variable extent. An extra joint is formed between the ala of sacrum and the elongated transverse process of the vertebra above on one or both sides. It leads to altered rotational movement of the lower spine, which gives rise to back pain. Spina bifida occulta (SBO) is another congenital malformation of the spine, which is detected incidentally because it does not cause any symptoms. We observed frequent co-existence of SBO and LSTV in patients attending our rheumatology clinic for lower back pain.

Filum terminale lipomas-the role of intraoperative neuromonitoring.

BACKGROUND: Filum terminale lipomas (FTL) represent a sub-type of spinal lipomas, where there is fatty infiltration of the filum. It becomes a surgical entity when it manifests as clinical or radiological tethered cord syndrome. Intraoperative neuromonitoring (IONM) has been suggested as a valuable tool in children for tethered cord surgeries. FTL is distinct and cannot be compared with complex tethered cord syndrome (TCS). Untethering an FTL is a relatively straightforward microsurgical exercise, usually based on anatomical findings. Neurological morbidity in FTL untethering is extremely low. The necessity of IONM in FTL has not been evaluated. The objective of this study was to identify the role of IONM in untethering an FTL METHODS: Available electronic data and case files were interrogated to identify children (0-18 years) who underwent an untethering of FTL between 2008 and 2019. We had a shift in our policy and tried to use IONM as often as possible in all tethered cord surgery from 2014. All children were categorised under 'IONM implemented' or 'no IONM' group. Outcomes analysed were as follows: (1) Clinical status on short-term and long-term follow-up, (2) alteration of surgical course by IONM and (3) complications specifically associated with IONM RESULTS: Among 80 children included in this study, IONM was implemented in 37 children and 43 children underwent untethering without IONM. 32.5% of children were 'syndromic'. Seventy-five percent of children were under age 3 years during surgery. Both groups (No IONM vs. IONM implemented) were well matched in most variables. Majority of 'no IONM' surgeries were performed prior to 2014. There was no neurological morbidity in the entire cohort. Mean duration of follow-up was 49.10 (± 33.67) months. Short-term and long-term clinical status remained stable in both cohorts. In 16 children, the filum was stimulated. Based on our protocol, majority had a negative response. One child showed a positive response, contradicted by thorough microscopic inspection. Despite a positive response, the filum was untethered. IONM was not associated with any complication in this study. CONCLUSION: FTL untethering is an inherently low-risk microsurgery in experienced hands with rarely reported neurological morbidity. IONM may not be required for all FTL and may be used more judiciously.

Characteristics and diagnostic factors associated with fresh lumbar spondylolysis in elementary school-aged children.

PURPOSE: We often encounter elementary school-aged children with fresh lumbar spondylolysis and non-union of bone. They may have factors that impede healing, and treatment outcomes need improvement. The purpose of this study was to investigate elementary school-aged patients with fresh lumbar spondylolysis and to identify characteristics that can aid in prompt diagnosis and proper therapy. METHODS: We retrospectively compared the characteristics of fresh lumbar spondylolysis in elementary school-aged children with those of older patients. We included patients aged 6-18 years with lower back pain and evidence of bone marrow oedema of lumbar pedicles on magnetic resonance imaging (MRI). The elementary school-aged group (group E) included 100 patients aged 6-12 years, and the senior group (group S) included 251 patients aged 13-18 years. We recorded patient sex, duration of lower back pain, injured site (lumbar level, unilateral/bilateral), presence of contralateral pars defect with evidence of high signal change on MRI (short tau inversion recovery), presence of spina bifida occulta (SBO), and follow-up treatment interruption rate. RESULTS: One-third of the patients in group E were female, and there was an even smaller proportion of females in group S. L5 lumbar spondylolysis was more common in group E. The treatment interruption rate was lower in group E. L5 SBO and contralateral pars defect were more common in group E. CONCLUSION: L5 lumbar spondylolysis, L5 SBO, and contralateral pars defect were important diagnostic factors in elementary school-aged patients. Identification of these characteristics will aid in prompt diagnosis and proper therapy.

Acute presentations of intradural lipomas: case reports and a review of the literature.

BACKGROUND: Lumbosacral lipomas (LLs) may remain asymptomatic or lead to progressive neurological deterioration. However, sudden neurological deterioration is a rare and severe event. Herein, we report rare occurrences of sudden clinical deterioration in two previously asymptomatic children harbouring intradural LLs without dermal sinus tracts or signs of occult dysraphism. A review of the pertinent literature is also included. CASE PRESENTATION: One child exhibited acute deterioration because of an epidural abscess associated with a filar lipoma without a sinus tract (probably caused by haematogenous spreading from a respiratory tract multiple infection), and the other child exhibited acute deterioration because of a very large, holocord syringomyelia-like cyst associated with a small conus lipoma. Both patients were 4 years old. In case #2, a previously undetected, severe tethered cord (conus at the S3-S4 level) was also present. A complete recovery was attained after an urgent surgical operation in both cases (in addition to targeted antibiotic therapy in case #1). All cases of deterioration in the literature were caused by abscess formation in dermal sinus tracts. CONCLUSIONS: Prophylactic surgery may be indicated even in asymptomatic children that have tethered cord and surgically favourable LLs (small dorsal and filar LLs), especially if the conditions are associated with progressive syringomyelia. Similarly, intradural dermal sinus tracts should be regarded as surgery-indicated, even if the conus is in its normal position and the patient is asymptomatic because there is a consistent risk of severe, infection-related complications. Finally, asymptomatic patients with filar LLs and a normally located conus can be candidates for surgery or an accurate clinical and radiological follow-up.

Zic Genes in Teleosts: Their Roles in Dorsoventral Patterning in the Somite.

The medaka contains seven zic genes, two of which, zic1 and zic4, have been studied extensively. The analyses are mainly based on the double anal fin (Da) mutant, which was isolated from the wild. Da is an enhancer mutant of zic1/zic4, and the expression of zic1/zic4 is specifically lost in the dorsal half of the somites, which leads to a mirror-image duplication of the ventral half across the lateral midline from larva to adult. The studies of medaka Da give us important insights into the function of zic1/zic4 in mesodermal tissues and also the mechanism of dorsoventral patterning in the vertebrate trunk region occurring during late development, which is a long-standing mystery in developmental biology. In this chapter, we introduce genomic organization of medaka zic genes and discuss their function, mainly focusing on zic1 and zic4 in dorsoventral patterning of the trunk region and possible connections to human congenital disorders.

[Spina bifida]. / Spina bifida.

Spina bifida is a congenital disorder with incomplete closure of the spinal column due to a bony vertebral defect. The term spina bifida literally means cleft spine and is used as a generic term of spinal dysraphism (Greek: Raphe = seam). It is a midline defect that occurs during the embryonic period. The insufficient closure of one or more vertebral arches is the result of an incomplete junction of the neural tube. Depending on the extent of the neural tube defect, various types of spina bifida can be differentiated. Closed spinal dysraphisms, also known as spina bifida occulta, are solely characterized by a bony defect of the vertebral arch, whereas, spina bifida cystica (synonym: open spina bifida or spina bifida aperta) can be distinguished by a protruding cyst, containing either meninges or meninges in combination with spinal cord tissue and are defined as open spinal dysraphisms.

Meningocele manqué: a comprehensive review of this enigmatic finding in occult spinal dysraphism.

The term meningocele manqué (MM) was coined in 1972 to describe a broad range of surgical findings characterized by intradural bands tethering neural structures to the dorsal dura. Over the following decades, reports continued to lump intradural tethering bands associated with a variety of comorbidities under the umbrella term MM. In more recent years, disorders previously called MM have been identified as embryologically distinct and were reclassified. While this sectioning continues, there remains a set of intradural tethering disorders for which no better term than MM exists. Herein, we comprehensively review the literature surrounding MM, including embryological disorders, clinical, radiographic, and surgical presentation, as well as alternative classification methods and MM treatment.

Incidence and type of foot deformities in patients with spina bifida according to level of lesion.

AIM: The previously suggested association between the incidence of high-level foot deformity and muscle imbalance is no longer supported, when evaluated independent from motor and sensory loss and level of lesion, by current studies. The purpose of this study was to evaluate the association between level of lesion and foot deformity. METHODS: Of 545 patients, a total of 136 (272 feet) patients admitted to the spina bifida clinic between 2010 and 2014 were included in this study. Levels of all lesions were evaluated using initial operation data, the motor-sensory exams, and direct radiography. All patients were categorized into four different groups: Thoracic region (group 1), high-level lumbar-L1-2 region (group 2), mild and lower lumbar regions (L3-4-5) (group 3), and Sacral region (group 4). RESULTS: The mean follow-up time was 34.9 months (range 8-176 months). Group 1, group 2, group 3, and group 4 included 24 (17.6%), 14 (10.3%), 19 (14%), and 79 (58.1%) patients with regards to level of lesion, respectively. The incidences of foot deformity were 85.4, 85.7, 81.5, and 50.6% in groups 1, 2, 3, and 4, respectively. Of all patients, 22% (61 feet) had clubfoot, 16% (44 feet) pes cavus, 10% (26 feet) pes valgus, 6% (17 feet) isolated equinus, 6 % (17 feet) pes calcaneus, and 5% (13 feet) metatarsus adductus. Patients without a foot deformity (81% of normal feet) usually had a lesion at the sacral level (p ≤ 0.05). On the other hand, isolated equinus (70%) and clubfoot (49%) deformities were mostly observed in spinal lesions (p > 0.05). The incidence of pes calcaneus, pes valgus, and adductus deformities inclined as the lesion level decreased (p > 0.05). CONCLUSION: In this study, it was concluded that foot deformities were directly related to the level of lesion. The comparison of higher and lower level lesions revealed that the types of foot deformity differed significantly. The muscle imbalance due to spina bifida was not sufficient to explain the pathology. On the other hand, the level of spinal lesion is an important factor for the type of deformity.

Spondylolysis and spina bifida occulta in pediatric patients: prevalence study using computed tomography as a screening method.

PURPOSE: The prevalence of spondylolysis reported from radiograph-based studies has been questioned in recent computed tomography (CT)-based studies in adults; however, no new data are available in pediatric patients. Spina bifida occulta (SBO), which has been associated to spondylolysis, may be increasing its prevalence, according to recent studies in adults in the last decades, but without new data in pediatric patients. We aimed to determine the prevalence of spondylolysis and SBO in pediatric patients using abdomen and pelvis CT as a screening tool. METHODS: We studied 228 patients 4-15 years old (107 males), who were evaluated with abdomen and pelvis CT scans for reasons not related to the spine. The entire lumbo-sacral spine was evaluated to detect the presence of spondylolysis and SBO. We compared the prevalence of spondylolysis in patients with and without SBO. A logistic regression analysis was performed to determine the effect of age and sex as independent predictors of spondylolysis and SBO. RESULTS: The prevalence of spondylolysis was 3.5 % (1.1-5.9 %); 2/8 patients presented with olisthesis, both with grade I slip. The prevalence of SBO was 41.2 % (34.8-59.2 %) (94 patients). Spondylolysis was not more frequent in patients with SBO than in patients without SBO. Male sex and decreasing age independently predicted the presence of SBO, but not of spondylolysis. CONCLUSION: We observed a 3.5 % prevalence of spondylolysis and a 41.2 % prevalence of SBO. SBO was significantly more frequent in males and younger patients.

Clinical features of patients with pars defects identified in adulthood.

PURPOSE: Lumbar spondylolysis is considered a stress fracture of the pars interarticularis that occurs during growth. However, it is sometimes insidious and identified in adults as pseudoarthrosis, the terminal-stage of spondylolysis. The purpose of this study was to identify the clinical features of patients with terminal-stage spondylolysis that first manifested during adulthood. PATIENTS AND METHODS: Thirty-six patients (21 men, 15 women; mean age 55.8 years; age range 25-77 years) with low back pain (LBP) were studied. In all patients, lumbar spondylolysis had not been diagnosed until the first visit to our hospital. Patient data collected were history of athletic activity and LBP during their growth period and radiological findings, such as spinal level, displacement, and spina bifida occulta (SBO). RESULTS: Among the 36 patients, including a patient with multi-level spondylolysis (L4 and L5), a total of 37 vertebrae with terminal-stage spondylolysis were identified. Twenty-three (89.2 %) of the 37 vertebrae had L5 spondylolysis. Sixteen patients (44.4 %) had no history of athletic activity, 26 (72.2 %) had no experience of LBP during their growth period, and 14 (38.9 %) had neither. Twenty of the 37 vertebrae (70.4 %) involved displacement (grade 1 = 14; grade 2 = 6). In nine patients (25.0 %; eight men, one woman), SBO of the sacrum was accompanied by L5 spondylolysis. CONCLUSIONS: Approximately 90 % of patients with terminal-stage spondylolysis that was first diagnosed in adulthood involved the L5. Also, about 40 % had no history of athletic activity or experience of LBP during their growth period. In addition, only some patients with L5 spondylolysis had SBO, and all but one of these patients was male. This suggests that male patients with L5 spondylolysis may have some congenital predisposition.

Spina bifida occulta at the lumbar spine level manifested as chronic low back pain and unpredictable neurologic deficit: A case report.

INTRODUCTION: Spina bifida occulta has a variety of symptoms that may hinder the diagnosis and subsequently delay appropriate treatment, causing a decrease in the patient's quality of life. This study aims to shed light on spina bifida occulta, with chronic low back pain as the predominant symptom, and the treatment applied in this case. PRESENTATION OF CASE: A 46-year-old male was diagnosed with spina bifida occulta at the 5th lumbar spine after 2 years of having chronic low back pain that radiated to the left leg. He was initially diagnosed with chronic low back pain and was treated with epidural steroid injections which yielded a suboptimal outcome. Through an MRI examination, a spina bifida occulta at the 5th lumbar spine was identified and the patient was then referred to a tertiary hospital for further spinal decompressive treatments. The decompression level was obtained intraoperatively with the aid of intraoperative neurophysiological monitoring. Following the procedure, pain had almost completely subsided, and the patient regained full function for his daily activities without any pain or restrictions. DISCUSSION: Non-specific clinical symptoms hindered the prompt diagnose of occult spinal dysraphism. MRI examinations of the spine is required and recommended for the characterization of intraspinal and perispinal abnormalities. Using intraoperative neurophysiological monitoring, we observed an improvement of nerve function at the L3-L5 level following decompression at the L3 level. CONCLUSION: The diagnosis of spina bifida can be challenging when patients are presented with non-specific clinical symptoms, in this case as pain. We recommend spinal MRI examinations in cases of chronic lower back pain that fail to improve following expected pain management and therapy. Intraoperative neurophysiological monitoring can be used to assist in the identification of the level for decompression, as well as the resolution of pain.

Paucity of evidence for urinary tract outcomes in closed spinal dysraphism: a systematic review.

OBJECTIVES: To describe the long-term upper (UUT) and lower urinary tract (LUT) outcomes in patients with closed spinal dysraphism (CSD). CSD differs from open spinal dysraphism (OSD) by its long asymptomatic course and consequent later diagnosis. The outcome of UUT and LUT function in adults with CSD is relatively unknown. PATIENTS AND METHODS: A systematic review was performed following the standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An extensive search was made of PubMed and EMBASE. Included were papers on adults with any form of primary CSD that described bladder and/or kidney function. Only English and Dutch language papers were included. Excluded were papers on patients aged <18 years and patients with secondary tethered cord following childhood OSD repair. International Continence Society terminology was used to describe LUT outcomes. RESULTS: Eventually, only seven studies (90 patients) were included and none of these described renal outcomes. Five of the seven papers were on outcomes after untethering surgery during adulthood. Urological complaints were present in 54/79 (68.4%) patients. Urodynamic studies (48 patients available) revealed detrusor underactivity in 46.5% of the evaluated cases, detrusor overactivity in 32.6% and normal findings in 16.3% of the studied patients. Symptomatic improvement after surgery for tethered cord occurred in 33.3-90.0%, depending on the subgroup studied. Urodynamic improvement rates ranged from 11.1% to 54.5% (but based on three studies with only 24 patients). Success of surgery depended on the time between onset of symptoms and operation, and (sometimes) type of lesion. CONCLUSIONS: Few data are available on long-term urological outcomes in adult patients with CSD. More extensive research on follow-up, including the functional status of the UUT, is recommended. Based upon the little evidence available, we think life-long follow-up (from birth into adulthood) of those with CSD and neurogenic bladder is advisable.

Spina bifida occulta: not to be overlooked in children with nocturnal enuresis.

OBJECTIVE: Previous reports have suggested that the incidence of spina bifida occulta in patients with nocturnal enuresis is higher than in the general population. However, the effect of spina bifida occulta on the response to nocturnal enuresis treatment is controversial. The purpose of this study was to investigate the relationship between spina bifida occulta and response to treatment of nocturnal enuresis. METHODS: Between 2006 and 2009, the records of 160 children with nocturnal enuresis were reviewed. Children with other organic urological disease or symptoms suggestive of spinal dysraphism were excluded. Plain radiography for the kidney-ureter-bladder was carried out before the start of the nocturnal enuresis treatment. Response to treatment of children with and without spina bifida occulta was compared. RESULTS: Of 160 children, 53 were girls; the mean age was 7.8 ± 2.06 years. The mean duration of treatment was 8.7 ± 9.29 months. Spina bifida occulta was detected in 43 children (26.9%). Spina bifida occulta affected L4 in four children, L5 in 12 children, S1 in 26 children and S2 in one child. There was a significant difference between the spina bifida occulta and non-spina bifida occulta groups in terms of outcome (P=0.002), with a complete response more likely in children without spina bifida occulta (P=0.005). None of the children with primary non-mono symptomatic nocturnal enuresis and spina bifida occulta showed a complete response. CONCLUSIONS: The presence of spina bifida occulta significantly affects the response to treatment in patients with nocturnal enuresis. Thus, verifying spina bifida occulta in this patient population can facilitate the prediction of the response to nocturnal enuresis treatment.

Hydromyelia and Intramedullary Abscess Complications of Dermal Sinus Tract: Rare Case in a Child.

The dermal sinus tract (DST) is an infrequent form of spina bifida occulta that can be complicated by infections. This is a case report of a child with a rare association of DST complications, namely hydromyelia and intramedullary abscess. A 1-year-old male child was admitted to the hospital with a history of fever and progressive loss of lower-limb movements and the presence of an ostium in the midline of the lumbar region and cutaneous stigmas with no secretion discharge. Computed tomography and magnetic resonance imaging (MRI) of the thoracolumbar spine revealed an extensive intradural T12-S1 abscess and cystic dilatation of the central medullary canal (hydromyelia) from T2 to T12. The surgery was conducted with the drainage of the large abscess and also improving hydromyelia. After 30 days of rehabilitation with physical therapy, the child could walk despite right crural monoparesis (possible L4/L5 injury). This report described a case of DST that showed a rare association of two complications, i.e., intramedullary abscess and hydromyelia, due to a late diagnosis. Sequelae could have been prevented with early diagnosis.

Effects of Spina Bifida Occulta on Bone Union in Fifth Lumbar Spondylolysis.

Introduction: The effect of spina bifida occulta (SBO) on bone union in lumbar spondylolysis is controversial. The study aim was to assess the effect of SBO on bone union after conservative treatment of L5 spondylolysis, the most common level. Methods: The study included 191 lesions in 145 patients (mean age, 14.0 years) with conservatively treated L5 spondylolysis. We examined the relationships between bone union after conservative treatment and the number of SBOs, levels, and single or multilevel status. Fisher's exact probability test, chi-square test, and Welch's T test were performed. Results: The SBO incidence was 53%, with at least one SBO at any vertebral level. SBO at S1 (p=0.034) or S2 (p=0.0003), two SBOs (p=0.0018), and three SBOs (p=0.011) were associated with a lower bone union rate. The bone union rate was significantly lower for lesions with SBOs at both S1 and S2 than without (42% vs. 79%; p<0.0001). Conclusions: The SBO incidence in L5 spondylolysis was 53%. SBO at S1 or S2 and a higher number of SBOs were associated with lower bone union rates. In particular, the bone union rate of lesions with SBOs at both S1 and S2 was <50%.

Chronic Hydrocephalus and Tethered Cord Masquerading as Postconcussive Syndrome.

We present a rare case of chronic hydrocephalus and tethered cord syndrome in a high-functioning asymptomatic college student. Her presentation was triggered by a fall, at which time, she developed subacute symptoms consistent with progressive increased intracranial pressure. After endoscopic third ventriculostomy for hydrocephalus, the patient presented with progressive bilateral lower extremity and sphincter symptoms, leading to spinal imaging and diagnosis of tethered cord syndrome with fatty filum. The patient was treated with tethered cord release and had a favorable long-term outcome. This case highlights the innocuous onset of 2 congenital diagnoses in adulthood seemingly associated with a mild traumatic injury. Furthermore, it shows classic imaging findings associated with chronic increased intracranial pressure, aqueductal stenosis, and tethered cord syndrome (preoperative and postoperative appearances), which serve an important educational role given the relate rarity of these coexisting diseases in adults.