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Introduction: Intramedullary metastases to the conus medullaris spinalis (IMCM) pose a rare problem in neurosurgical oncology and are usually encountered as a complicated clinical scenario in the setting of advanced systemic malignancy with poor overall survival. Despite the progress in interdisciplinary oncological care, their management remains complicated. Research Question: We performed a PRISMA-guided literature search to achieve a pooled analysis of all previously reported IMCM cases that contained detailed clinical data on this problem to investigate the currently employed management options and respective outcomes. We obtained a clinical vignette and performed a comprehensive narrative review of IMCM management. Materials and Methods: The PubMed/MEDLINE/Google Scholar, Cochrane and Embase databases were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All relevant publications retrieved were subjected to full-text analysis in detail and pertinent information was extracted. Results: The most common systemic primary tumor site as the origin of IMCM was the lung, followed by the breast. Overall, the pooled median survival was 6 months (range 0.5–36 months). Patients who received both surgery and radiation therapy had the longest overall survival (OS) (mean 9.9 months) and those who received no oncological treatment (neither surgery nor adjuvant therapy) had the shortest OS (mean 3.6 months). In cases where surgical resection was performed as part of the treatment plan for metastases, those with partial tumor resection had a more favorable neurological outcome than patients who underwent aggressive gross total resection. Conclusions: Based on the results of our analysis, we find that diligent microsurgical resection (subtotal or total) followed by radiation therapy appears as an effective and suitable treatment in select patients with IMCM. When surgery is not feasible as part of the treatment algorithm, radiation therapy alone (conventional or radiosurgery) also appears to be a suitable treatment option that confers a benefit to the patient. [ABSTRACT FROM AUTHOR]

Lower motor neuron (LMN) damage results in denervation of the associated muscle targets and is a significant yet under-appreciated component of spinal cord injury (SCI). Denervated muscle undergoes a progressive degeneration and fibro-fatty infiltration that eventually renders the muscle non-viable unless reinnervated within a limited time window. The distal nerve deprived of axons also undergoes degeneration and fibrosis making it less receptive to axons. In this review, we describe the LMN injury associated with SCI and its clinical consequences. The process of degeneration of the muscle and nerve is broken down into the primary components of the neuromuscular circuit and reviewed, including the nerve and Schwann cells, the neuromuscular junction, and the muscle. Finally, we discuss three promising strategies to reverse denervation atrophy. These include providing surrogate axons from local sources; introducing stem cell-derived spinal motor neurons into the nerve to provide the missing axons; and finally, instituting a training program of high-energy electrical stimulation to directly rehabilitate these muscles. Successful interventions for denervation atrophy would significantly expand reconstructive options for cervical SCI and could be transformative for the predominantly LMN injuries of the conus medullaris and cauda equina. [ABSTRACT FROM AUTHOR]

BACKGROUND: Currently, there are a variety of methods for ultrasound to localize the conus medullaris. A concern is that measured values can be influenced by variations in spinal flexion and extension. OBJECTIVE: To overcome this limitation, the present study measures the horizontal distance (HD) between the end of the conus medullaris and the caudal edge of last vertebral body ossification in normal fetus at different gestational weeks, and analyzes the relationship between the measured value and fetal growth, as well as the utility of these measurements in assessing the position of the conus medullaris. METHODS: A total of 655 fetuses at gestational weeks 18–40, who underwent routine prenatal ultrasound, were selected in the study. We measured the distance between the end of the cone of the fetal spinal cord and the caudal end of the final vertebral ossification center (Distance1, D1), the distance between the end of the spinal cord cone and the intersection of the extension of D1 with the caudal skin (Distance2, D2), and HD. We analyzed the correlation between the measurements and gestational weeks, established normal reference values, the ratio of D1, D2 and HD to the commonly used growth parameters was calculated. The ratios of D1, D2, HD and the application value of each ratio phase were analyzed, and the reliability analysis of repeated measurement results among physicians was performed. RESULTS: D1, D2 and HD exhibited strong linear correlations with gestational weeks. Among the ratios of D1, D2 and HD to common growth parameters, D2/FL stabilized after 20 weeks of gestation and consistently exceeded 1. Repeatability tests between D1, D2 and HD showed good reliability (P > 0.05). CONCLUSION: D1, D2 and HD are significantly correlated with gestational age. Horizontal distance measurement can effectively determine the position of fetal conus medullaris, enabling rapid prenatal evaluation of low position of conus medullaris and excluding the possibility of tethered cord. [ABSTRACT FROM AUTHOR]

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Capillary hemangiomas, usually found in skin and mucosal tissues, are rarely encountered within the spinal cord, presenting a significant diagnostic challenge. We report a rare case of intradural extramedullary capillary hemangioma at the conus medullaris in a 66-year-old female patient. Our initial diagnosis leaned towards a cystic hemangioblastoma based on MRI findings due to the presence of cystic formation with an enhanced mural nodule. However, surgical exploration and subsequent pathological examination revealed the lesion as a capillary hemangioma. To the authors' knowledge, this case may represent the first documented instance of a spinal capillary hemangioma that mimics a cystic hemangioblastoma. [ABSTRACT FROM AUTHOR]

This study aimed to ascertain the conus medullaris position by counting the number of ossification centers in the vertebral bodies below the conus medullaris endpoint (N) and assess its utility in screening for closed spinal dysraphism and tethered cord syndrome. A total of 900 normal fetuses and 146 fetuses with closed spinal dysraphism or tethered cord syndrome were included in this study. The N values were tallied and compared along the spinal longitudinal plane. The receiver operating characteristic curve was utilized, and the cut-off value of N was analyzed. The counting of N was successfully performed in 856 normal and 146 abnormal fetuses. In the normal group, an increase in N with gestational age was observed. Specifically, in the subgroup of 17–20 wk fetuses, N was ≥6 in 117 out of 131 cases. This figure increased to 211 out of 213 in 21–24 wk and 512 out of 512 in 25–41 wk, respectively. Cases with N ≥7 accounted for 715 out of 856 fetuses in the 17–41 wk range. In the abnormal group, N was less than 7 in 152 out of 163 fetuses, showing statistical differences between the two groups. With a cut-off value of 6.5, specificity and sensitivity reached 93.3% and 83.5%. The counting of N was found to be a straightforward and efficient method for evaluating the position of the conus medullaris. [ABSTRACT FROM AUTHOR]

Intramedullary spinal cord metastasis (ISCM), though rare, represents a potentially debilitating manifestation of systemic cancer. With emerging advances in cancer care, ISCMs are increasingly being encountered in clinical practice. Herein, we describe one of the larger retrospective single institutional case series on ISCMs, analyze survival and treatment outcomes, and review the literature. All surgically evaluated ISCMs at our institution between 2005 and 2023 were retrospectively reviewed. Demographics, tumor features, treatment, and clinical outcome characteristics were collected. Neurological function was quantified via the Frankel grade and the McCormick score (MCS). The pre- and post-operative Karnofsky performance scores (KPS) were used to assess functional status. Descriptive statistics, univariate analysis, log-rank test, and the Kaplan–Meier survival analysis were performed. A total of 9 patients were included (median age 67 years (range, 26–71); 6 were male). Thoracic and cervical spinal segments were most affected (4 patients each). Six patients (75%) underwent surgical management (1 biopsy and 5 resections), and 3 cases underwent chemoradiation only. Post-operatively, 2 patients had an improvement in their neurological exam with one patient becoming ambulatory after surgery; three patients maintained their neurological exam, and 1 had a decline. There was no statistically significant difference in the pre- and post-operative MCS and median KPS scores in surgically treated patients. Median OS after ISCM diagnosis was 7 months. Absence of brain metastasis, tumor histology (renal and melanoma), cervical/thoracic location, and post-op KPS ≥ 70 showed a trend toward improved overall survival. The incidence of ISCM is increasing, and earlier diagnosis and treatment are considered key for the preservation of neurological function. When patient characteristics are favorable, surgical resection of ISCM can be considered in patients with rapidly progressive neurological deficits. Surgical treatment was not associated with an improvement in overall survival in patients with ISCMs. [ABSTRACT FROM AUTHOR]

Teratomas constitute 0.1% of all spinal cord tumors and contain tissues originating from the three germ layers. The aim of surgery in spinal teratomas is total excision. However, total excision of tumors in the conus medullaris may lead to potentially significant morbidities. We aimed to present an epidermoid cyst (EC) after subtotal resection of teratomas. A 19-year-old woman complained of low back pain and numbness in the posterior aspect of the left leg. Magnetic resonance imaging (MRI) showed a tethered cord and an intradural lesion at the L4 level. During surgery, part of the capsule was left. Histopathological examination was reported as a benign cystic teratoma. Thirty-three months later, a control follow-up MRI showed a cystic lesion at the L4 level. After the total excision of the lesion, a neuro deficit developed. Histopathological examination was reported as EC. Spinal ECs account for less than 1% of spinal tumors. These tumors are lined with stratified squamous epithelium, similar to the skin's epidermis, and arise from the pathological displacement of epidermal cells into the spinal canal. It should be remembered that EC may develop after incomplete resection of conus medullaris-localized teratomas, and complete resection of these masses may result in neurological deficits. [ABSTRACT FROM AUTHOR]

Background: Most posttraumatic syringomyelias occur in the cervical or thoracic spinal cord, where they contribute to myelopathic deficits. Here, a 40-year-old patient presented with the left leg monoparesis due to syringomyelia involving the conus medullaris 10 years after an L2 vertebral "crush" fracture. Case Description: Ten years following an L2 vertebral "crush" fracture, a 40-year-old male presented with the new onset of left lower leg paresis. The magnetic resonance imaging showed a T12-L1 syrinx associated with accompanying high-intensity areas above the syrinx located between the T11 and T12 levels. One month after placing a syringosubarachnoid (SS) shunt, both the syrinx and high-intensity area rapidly disappeared, and the left distal motor weakness resolved. Conclusion: Ten years following an L2 "crush" fracture, a 40-year-old male presented with the new onset of a cauda equina syndrome secondary to a posttraumatic T12-L1 syringomyelia causing expansion of the conus medullaris. [ABSTRACT FROM AUTHOR]

Background: Patients affected by Von Hippel-Lindau (VHL) are prone to develop central nervous system neoplasms such as hemangioblastomas (HBs). Myxopapillary ependymoma (MPE) is not commonly associated with VHL disease. Case Description: We present the first case of a VHL patient affected by simultaneous silent cauda equina MPE and a symptomatic conus medullaris HB. The patient was first operated for systemic tumors and followed for asymptomatic HBs. Simple surveillance was maintained until neurological symptoms appeared. Regular followup demonstrated objective growth of the cystic conus medullaris tumor while the cauda equina lesion remained stable. Surgery was performed to avoid further neurological worsening. Histopathological examination showed conus medullaris HB and a nearby cauda equina MPE. Conclusion: Simultaneous spinal HBs and isolated MPE may exceptionally occur in VHL patients. [ABSTRACT FROM AUTHOR]

Endris Hussen,1 Samson Aboye,1 Merhawi Leake,2 Fadil Nuredin Abrar3 1Department of Neurosurgery, St. Paul’s Millennium Medical College, Addis Ababa, Ethiopia; 2Minilik II Comprehensive Specialized Hospital, Addis Ababa, Ethiopia; 3Addis Ababa University College of Medicine and Health Sciences Hospital, Addis Ababa, EthiopiaCorrespondence: Endris Hussen, Department of Neurosurgery, Senior Neurosurgical Resident, St. Paul’s Millennium Medical College, P.O. BOX: 1271, Addis Ababa, Ethiopia, Tel +251905484748, Email idrisdoc2007@gmail.comBackground: Central nervous system tumors are usually located in the brain, and spinal cord tumors account for approximately 20% of central nervous system tumors. Epidermoid cysts constitute < 1% of all intraspinal tumors. It consists of squamous epithelial-lined cysts containing keratin, cholesterol, and cellular granules. Epidermoid cysts can be classified as congenital, acquired, extradural, extramedullary, or intramedullary according to etiology and location. The intradural intramedullary type is uncommon.Case Presentation: An 11-year-old female patient had back pain with radiation to both lower extremities but worsened on the left side for 5 years. On neurological examination, motor strength was 3/5 for hip flexion and knee extension bilaterally and 5/5 for other key muscle groups. Contrast-enhanced lumbosacral magnetic resonance imaging (MRI) revealed T1 hypointense and T2 hyperintense lesions in the L2-L4 intramedullary conus and cauda equina. Laminectomy and near total resection were done, and histopathological examination revealed an epidermoid cyst. On the third postoperative day, the patient was discharged with completely resolved back pain and an improvement in lower extremity motor power. At monthly follow-up visits for a further 6 months, her back pain and weakness completely resolved, and she had no neurologic deficits. A postoperative lumbosacral MRI was done and confirmed near total excision of the tumor.Conclusion: Intramedullary conus epidermoid cysts are rare but not unknown to neurosurgeons. MRI with diffusion-weighted images (DWI) is an imaging modality of choice. Asymptomatic patients can be conservatively treated. Once the patient has progressive symptoms and signs of compression, surgical excision is recommended. Meticulous electrocauterization may help decrease tumor regrowth in the remnant capsule, which is recommended. Avoiding leakage of cyst fluid into the subarachnoid space helps to avoid postoperative chemical meningitis. Radiotherapy is an option for the management of multiple recurrences.Keywords: epidermoid cyst, conus medullaris, cauda equina, intramedullary

A 29-year-old man from Comoros presented with rapidly progressive paraplegia and sexual dysfunction. Magnetic resonance imaging (MRI) showed a contrast-enhanced conus medullaris lesion. Differential diagnoses included tumors, abscesses, and inflammatory diseases. Neurosurgery was delayed to complete examinations. Cerebral MRI showed three abscesses. Body computed tomography scan showed supracentimetric polyadenopathies, pulmonary nodules, prostatic lesion, and enhanced seminal vesicle, with hypermetabolism on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose scan. Histology of lymph node biopsy showed granulomatous infiltration without acid-fast bacilli, and positive polymerase chain reaction for Mycobacterium tuberculosis. Lymph node culture was positive after 2 months, urine culture after 3 weeks, but cerebrospinal fluid and sputum cultures were negative. A 1-year antituberculosis therapy was initiated, associated with corticosteroids because the patient developed tuberculosis-immune reconstitution syndrome, revealed by the recurrence of neurological symptoms. After 2 months the patient completely recovered and could run. MRI showed stability of the voluminous tuberculoma with decrease of medullary edema. Avoiding surgery in those cases may prevent iatrogenic neurological deterioration. [ABSTRACT FROM AUTHOR]

Introduction: Intramedullary metastases to the conus medullaris spinalis (IMCM) pose a rare problem in neurosurgical oncology and are usually encountered as a complicated clinical scenario in the setting of advanced systemic malignancy with poor overall survival. Despite the progress in interdisciplinary oncological care, their management remains complicated. Research Question: We performed a PRISMA-guided literature search to achieve a pooled analysis of all previously reported IMCM cases that contained detailed clinical data on this problem to investigate the currently employed management options and respective outcomes. We obtained a clinical vignette and performed a comprehensive narrative review of IMCM management. Materials and Methods: The PubMed/MEDLINE/Google Scholar, Cochrane and Embase databases were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All relevant publications retrieved were subjected to full-text analysis in detail and pertinent information was extracted. Results: The most common systemic primary tumor site as the origin of IMCM was the lung, followed by the breast. Overall, the pooled median survival was 6 months (range 0.5–36 months). Patients who received both surgery and radiation therapy had the longest overall survival (OS) (mean 9.9 months) and those who received no oncological treatment (neither surgery nor adjuvant therapy) had the shortest OS (mean 3.6 months). In cases where surgical resection was performed as part of the treatment plan for metastases, those with partial tumor resection had a more favorable neurological outcome than patients who underwent aggressive gross total resection. Conclusions: Based on the results of our analysis, we find that diligent microsurgical resection (subtotal or total) followed by radiation therapy appears as an effective and suitable treatment in select patients with IMCM. When surgery is not feasible as part of the treatment algorithm, radiation therapy alone (conventional or radiosurgery) also appears to be a suitable treatment option that confers a benefit to the patient.

Lower motor neuron (LMN) damage results in denervation of the associated muscle targets and is a significant yet under-appreciated component of spinal cord injury (SCI). Denervated muscle undergoes a progressive degeneration and fibro-fatty infiltration that eventually renders the muscle non-viable unless reinnervated within a limited time window. The distal nerve deprived of axons also undergoes degeneration and fibrosis making it less receptive to axons. In this review, we describe the LMN injury associated with SCI and its clinical consequences. The process of degeneration of the muscle and nerve is broken down into the primary components of the neuromuscular circuit and reviewed, including the nerve and Schwann cells, the neuromuscular junction, and the muscle. Finally, we discuss three promising strategies to reverse denervation atrophy. These include providing surrogate axons from local sources; introducing stem cell-derived spinal motor neurons into the nerve to provide the missing axons; and finally, instituting a training program of high-energy electrical stimulation to directly rehabilitate these muscles. Successful interventions for denervation atrophy would significantly expand reconstructive options for cervical SCI and could be transformative for the predominantly LMN injuries of the conus medullaris and cauda equina.

Introduction: Generally, the spinal cord ends at the level between the first and second lumbar vertebrae. There are many studies published globally, yet no article has been published concerning this title in our settings. The objective of this study was to determine the tip level of conus medullaris by the Magnetic Resonance Imaging (MRI) in living humans in Nepalese population. Methods: Images of the MRI done between August 2019 to June 2021 were accessed through the database of the radiology department for defining the level of conus medullaris. The termination level of conus medullaris was rescored in relation to the upper, mid, and lower third of the adjacent vertebrae and the intervertebral disc. Input data was processed in Microsoft Excel which was later analyzed by SPSS 20.0. Results: Of the total, 202 study population, a higher number of spinal cords terminated at lower one-third of L1 vertebrae, accounting for 51 (females 26 and males 25) followed by L1-L2 intervertebral disc comprising only 35 (males 19; females 16). No significant differences in number existed between the two sexes having conus medullaris termination at both levels. Most of the cases who were in the age group of 40-49 years old, termination of CM was noted in L1 with the most common shape being the central type C, accounting for 38% (78/202). Conclusions: The conus medullaris was terminated mostly at lower one third of L1 vertebral body in our settings with no gender difference.

Background: Traditional spine magnetic resonance imaging (MRI) protocols require sedation in young children and uncooperative patients. There is an increased interest in non-sedated pediatric MRI protocols to reduce risks associated with anesthetic agents and improve MRI access. Objective: To evaluate the image quality of pediatric non-sedated fast spine MRI. Materials and methods: We retrospectively reviewed 69 pediatric non-sedated fast spine MRI exams performed in 57 patients. Two blinded readers provided image quality ratings for the evaluation of bones, cranio-cervical junction, cerebrospinal fluid (CSF) spaces, spinal cord, soft tissues, ligaments, and overall diagnostic quality on a 1–5 scale, and determined whether there was evidence of syringomyelia, abnormal conus medullaris position, or filum terminale abnormality. Results: Mean patient age was 7.2 years (age range ≤ 1–17). Indications included syringomyelia (n=25), spinal dysraphism (n=4), combination of both syringomyelia and spinal dysraphism (n=8), and other miscellaneous indications (n=32). The inter-observer agreement ranged between moderate and very good for each variable (Cohen's weighted kappa] range=0.45–0.69). The highest image quality ratings were given to CSF spaces (mean image quality=3.5/5 ± 0.8) and cranio-cervical junction evaluations (3.5/5 ± 0.9). Overall diagnostic quality was worst in the <5 years group (P=0.006). Readers independently identified a cervical spinal cord syrinx in 6 cases, and 1 mm spinal cord central canal dilation in one case. Readers agreed on the position of the conus medullaris in 92% of cases (23/25 cases). Conclusion: Non-sedated pediatric spine MRI can be an effective diagnostic test to evaluate for spine pathology, especially syringomyelia, Chiari malformation, and conus medullaris anatomy. [ABSTRACT FROM AUTHOR]

Background and purpose: Spinal cord lesions are observed in 40% of all central nervous system lesions in intravascular large B‐cell lymphoma (IVLBCL). However, because IVLBCL is a very rare disease, its clinical features are not well defined, which may delay appropriate diagnosis and treatment, whilst the acute to subacute course of brain lesions in patients with IVLBCL is well established. Therefore, this study aimed to clarify the clinical features of spinal cord lesions in patients with IVLBCL. Methods: The medical records of patients with IVLBCL admitted to our hospital between 2010 and 2020 were searched. The inclusion criteria were preceding neurological symptoms without non‐neurological symptoms and pathologically confirmed IVLBCL in various organs. Clinical features of spinal cord involvement in patients with IVLBCL were assessed and distinguished from those of brain involvement. Results: Sixteen consecutive patients with IVLBCL were divided into two groups: six patients with spinal involvement (spinal cord type) and 10 patients with brain involvement (brain type). In the spinal cord type, four patients had chronic progression and two had subacute progression. Acute progression (0% vs. 80.0%) and sudden onset (0% vs. 50.0%) occurred significantly less frequently in the spinal cord than in the brain. All spinal cord lesions involved the conus medullaris. Conclusions: Spinal cord involvement in IVLBCL has a predominantly chronic progressive course that is exclusive to brain involvement. Conus medullaris lesions are suggestive of IVLBCL and are useful for early and accurate diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Key Clinical Message: In conus medullaris, mature teratomas are rare. We report a case of a 40‐year‐old man who presented with urinary incontinence, low back pain, and muscle weakness. Magnetic resonance imaging revealed a mass in conus medullaris (T11–L1), further confirmed as a mature teratoma by pathological examination. We identified 63 cases of conus medullaris teratoma over the past two decades by systematically analyzing the case reports. Findings demonstrated that most cases were diagnosed in the fourth decade of life, with the majority of cases (57.6%) being male. Lower back pain, radiating pain in the extremities, hypoesthesia, and urinary dysfunction are the most common clinical presentations among patients with teratoma of conus medullaris. Mature teratoma is the dominant pathologic subtype of teratomas in this region, comprising more than 95% of cases. Our case highlights the importance of considering spinal teratoma as a differential diagnosis in patients presenting with urinary incontinence and lumbar pain. [ABSTRACT FROM AUTHOR]

Key Clinical Message In conus medullaris, mature teratomas are rare. We report a case of a 40‐year‐old man who presented with urinary incontinence, low back pain, and muscle weakness. Magnetic resonance imaging revealed a mass in conus medullaris (T11–L1), further confirmed as a mature teratoma by pathological examination. We identified 63 cases of conus medullaris teratoma over the past two decades by systematically analyzing the case reports. Findings demonstrated that most cases were diagnosed in the fourth decade of life, with the majority of cases (57.6%) being male. Lower back pain, radiating pain in the extremities, hypoesthesia, and urinary dysfunction are the most common clinical presentations among patients with teratoma of conus medullaris. Mature teratoma is the dominant pathologic subtype of teratomas in this region, comprising more than 95% of cases. Our case highlights the importance of considering spinal teratoma as a differential diagnosis in patients presenting with urinary incontinence and lumbar pain.

We assessed the frequency and type of associated congenital anomalies encountered with fetal tethered spinal cord (TSC) determined prenatally. A retrospective review was conducted based on the associated fetal abnormalities following diagnosis of low-lying fetal conus medullaris during the prenatal ultrasound. Of the 26 fetuses with low-lying conus medullaris, four were solitary TSC and 22 had TSC combined with associated congenital malformations, including four cases with spina bifida occulta, four cases with spina bifida aperta, one case with severe hydrocephalus, and 13 cases with multisystem congenital malformations. Among all the 13 cases with combined multisystem congenital malformations, four cases had vertebral defects, anal anomalies, cardiac defects, trachea-esophageal fistula, renal anomalies, and limb anomalies (VACTERL) syndrome, two cases had combined kidney development abnormalities, one case had cloacal exstrophy (OEIS syndrome), and six cases had chromosomal abnormalities (one case of chromosome 7q deletion, two cases of trisomy 13 syndrome, one case of trisomy 18 syndrome, one case of trisomy 9 syndrome, and one case of chromosome 4p deletion). Low-lying conus medullaris found during prenatal ultrasound examination were often associated with neural tube malformations or multi-systemic complex developmental malformations. The frequency of chromosomal abnormalities was 23.1%. [ABSTRACT FROM AUTHOR]

Joanne Du,1 Catherine Roth,2 Sujana Dontukurthy,3 Joseph D Tobias,2,4 Giorgio Veneziano2,4 1The Ohio State University College of Medicine, Columbus, OH, USA; 2Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 3Department of Anesthesiology, Valley Children’s Hospital, Madera, CA, USA; 4Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Giorgio Veneziano, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH, 43205, USA, Tel + 1 614-722-4200, Email Giorgio.Veneziano@nationwidechildrens.orgPurpose: Awake spinal anesthesia continues as an alternative to general anesthesia for infants. Standard clinical practice includes the manual palpation of surface landmarks to identify the desired intervertebral space for lumbar puncture (LP). The current study investigates the accuracy of manual palpation for identifying the intended intervertebral site for LP, using ultrasonography for confirmation and to determine the interspace where the conus medullaris ends.Patients and Methods: After informed parental consent, patients less than one year of age undergoing spinal anesthesia for lower abdominal, urologic, or lower extremity surgical procedures were included. Patients were held in the seated position and an attending pediatric anesthesiologist or pediatric anesthesiology fellow declared the vertebral interspace intended for needle insertion, palpated surface landmarks, and placed a mark at the site. A research anesthesiologist then determined the actual vertebral interspace of the marked site and the location of the conus medullaris using ultrasonography. The time to complete both techniques (manual palpation and ultrasonography) was recorded.Results: The study cohort included 50 infants (median age of 7 months). Sixteen vertebral interspaces (32%) were inaccurately marked. One was marked two spaces higher than intended, ten were marked one space higher than intended, and five were marked one space lower than intended. In one patient, the intended vertebral interspace for the lumbar puncture overlaid the conus medullaris. The median time required was 25 seconds (IQR 14.3, 32) for palpation and 39 seconds (IQR 29, 63.8) for ultrasonography.Conclusion: Manual palpation of surface landmarks to determine the correct interspace for LP for spinal anesthesia in infants is inaccurate. The time required to perform spinal ultrasonography in infants for determination of the optimal site for LP is brief and may be useful in ensuring accurate identification of the correct interspace and the location of the conus medullaris.Keywords: spinal anesthesia, infant, ultrasonography, palpation, lumbar puncture, conus medullaris

Background: Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a rare but potentially reversible autoimmune encephalopathy. The most frequent neuroimaging correlates are normal brain MRI or non-specific white matter hyperintensities. Methods: We present the first description of conus medullaris involvement, also providing an extensive review of MRI patterns described so far. Results: Our results show that in less than 30% of cases, it is possible to find focal SREAT neuroanatomical correlates. Among these, T2w/FLAIR temporal hyperintensities are the most frequent, followed by basal ganglia/thalamic and brainstem involvement, respectively. Conclusions: Unfortunately, spinal cord investigation is an uncommon practice in the diagnostic approach of encephalopathies, thus neglecting potential pathological lesions of the medulla spinalis. In our opinion, the extension of the MRI study to the cervical, thoracic, and lumbosacral regions may allow finding new, and hopefully specific, anatomical correlates. [ABSTRACT FROM AUTHOR]

Purpose: To explore the position change of fetal conus medullaris by ultrasound, and to propose gestational age-specific references for the lower limits of fetal conus medullaris level. Methods: We prospectively collected the imaging and clinical data of fetuses whose mothers accepted routine prenatal ultrasonic follow-ups in the Department of Medical Ultrasonics, Chinese PLA General Hospital, between November 2020 and April 2021. By assigning to the conus medullaris levels, calculating statistical data, and performing linear regression analysis, we determined the correlation between the conus medullaris level and gestational week, as well as between the 95th percentile of the conus medullaris level, i.e., the lower limit of the conus medullaris level, and gestational week. Results: We included 1202 different fetuses at 17–40 gestational weeks in the study. Both the conus medullaris level and the 95th percentile of the conus medullaris level were linearly correlated with gestational week. We calculated the adjusted values of the lower limits of fetal conus medullaris levels, that is, the theoretical references of the lower limits, according to the linear regression equation, and composed a comparison table. Conclusion: The fetal conus medullaris position continues changing cranially with gestational weeks during the whole pregnancy. The conus medullaris of a term fetus should not lie below the L2 vertebra level at birth. We proposed reference criteria of fetal low-lying conus medullaris for each gestational week from 17 to 40 weeks of gestational age, which potentially help prompt diagnosis and improve prognosis of fetal tethered cord syndrome. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies have reported that the conus medullaris (CM) is located between T12 and L2 in most adults, but no significant ascent has been observed during childhood. There is evidence that the normal position of the CM in an adult is acquired at birth in the majority of cases. Studies have shown that there are differences in CM levels in neonates. This situation causes problems for interventional procedures in the neonatal period. The aim of this study is to determine CM levels in preterm/term neonates using ultrasound (US). Materials and Methods: Newborn infants (gestational age: 24-43 weeks) admitted to the neonatal intensive care unit between March 2020 and June 2021 were evaluated for CM levels by the postnatal US. Infants with central nervous system abnormalities, dysmorphic features, somatic or various genetic diseases, or their parent's refusal to participate were excluded from the study. Results: Of the 189 neonates infants included in our study, 85 (44.6%) were female, 104 (55.4%) were male, 139 (73.54%) were preterm (24-36 weeks), and 50 (26.46%) were term (37-42 weeks) neonates. As a result of the US performed on the first day of 189 neonates, CM levels, 31 (16.4%) were L1, 31 (16.4%) were L1-2, and 71 (37.6%) were L2. There is a strong correlation between birth weight and birth week (r 0.84). There is a negative relationship between birth weight and CM level (r -0,20), gestational age, and CM level (r -0,23). Conclusion: Conus medullaris level was negatively correlated with gestational age and increased with advancing gestational age. In addition, the CM level shows a slower rise at 28-40 weeks of postmenstrual age and reaches the normal level (L1-L2) in the neonatal period, as in adults. Knowing the level of the CM in the newborn period will ensure that spinal procedures such as lumbar puncture to be applied to the spinal region can be performed safely. [ABSTRACT FROM AUTHOR]

Purpose: This study assessed the position of the termination of the conus medullaris (the point where the spinal cord tapers to an end) and thecal sac (the sheath of dura mater that surrounds the spinal cord and caudal nerve roots) in a large pediatric population, to characterise the nature of the pediatric Gaussian distribution and assess whether age affected the distribution. The study further aimed to assess the effect of gender on termination positions. Methods: A total of 520 MRI spine studies of children aged between 1 month and 19 years old were collected from two pediatric tertiary referral centres in the UK and Italy. Studies with pathological findings were excluded, and normal scans were found using keyword search algorithms on a database of radiologists' reports. The reported scans were individually assessed and reviewed by two experienced neuroradiologists. The termination points of the conus medullaris and thecal sac were determined for each study. Local IRB approvals were sought. Results: The results showcased a Gaussian distribution in both conus medullaris (r=0.8997) and thecal sac termination levels (r=0.9639). No statistically significant results were noted with increasing age for the termination positions of the conus medullaris or thecal sac (p = 0.154, 0.063). No statistical significance was observed with gender variation with either anatomical landmark. A weak positive correlation was observed between the termination levels of the conus medullaris and the thecal sac (r=0.2567) Conclusion: Termination levels across all pediatric age range followed a Gaussian distribution. Knowledge of normal termination levels has relevant clinical implications, including the assessment of patients with suspected spinal dysraphism. [ABSTRACT FROM AUTHOR]

Aim: Reporting a rare case of mature cystic teratoma of spinal cord in an adult Background: Teratomas of the central nervous system are rare lesions accounting for less than 0.5-2% of all CNS tumors. Most of these are found in pediatric age group and favor sellar - suprasellar, pineal and sacro-coccygeal regions. Their occurrence in spinal cord in an adult is incredibly rare. Case presentation: A 22-year-old male presented with low back ache and weakness of both lower limbs. Clinical examination and radiological workup revealed presence of a cystic lesion causing diffuse enlargement of the cord from L1 to L5-S1. Histopathological examination of the excised lesion revealed it to be teratoma. Conclusion and clinical significance: Mature teratoma of the spinal cord in adults is extremely rare occurrence. However, this diagnosis should be kept in mind when evaluating a cystic lesion of cord even in adults. Maximal safe resection of the lesion results in prolonged deficit free survival. [ABSTRACT FROM AUTHOR]

Spinal cord (SC) anatomy is often assimilated to a morphologically encapsulated neural entity, but its functional anatomy remains only partially understood. We hypothesized that it could be possible to re-explore SC neural networks by performing live electrostimulation mapping, based on "super-selective" spinal cord stimulation (SCS), originally designed as a therapeutical tool to address chronic refractory pain. As a starting point, we initiated a systematic SCS lead programming approach using live electrostimulation mapping on a chronic refractory perineal pain patient, previously implanted with multicolumn SCS at the level of the conus medullaris (T12-L1). It appeared possible to (re-)explore the classical anatomy of the conus medullaris using statistical correlations of paresthesia coverage mappings, resulting from 165 different electrical configurations tested. We highlighted that sacral dermatomes were not only located more medially but also deeper than lumbar dermatomes at the level of the conus medullaris, in contrast with classical anatomical descriptions of SC somatotopical organization. As we were finally able to find a morphofunctional description of "Philippe–Gombault's triangle" in 19th-century historical textbooks of neuroanatomy, remarkably matching these conclusions, the concept of "neuro-fiber mapping" was introduced. [ABSTRACT FROM AUTHOR]

Although brain metastasis is usual in breast cancer, metastasis of the conus medullaris is extremely infrequent. Herein, we present the first case of triple-positive subtype breast cancer with conus medullaris metastasis. The patient admitted with paraplegia and neurological dysfunction improved after the removal of the mass, followed by radiotherapy. We also discuss the clinical characteristics and available therapies for conus medullaris metastases. [ABSTRACT FROM AUTHOR]

Aim: Reporting a rare case of mature cystic teratoma of spinal cord in an adult Background: Teratomas of the central nervous system are rare lesions accounting for less than 0.5-2% of all CNS tumors. Most of these are found in pediatric age group and favor sellar - suprasellar, pineal and sacro-coccygeal regions. Their occurrence in spinal cord in an adult is incredibly rare. Case presentation: A 22-year-old male presented with low back ache and weakness of both lower limbs. Clinical examination and radiological workup revealed presence of a cystic lesion causing diffuse enlargement of the cord from L1 to L5-S1. Histo-pathological examination of the excised lesion revealed it to be teratoma. Conclusion and clinical significance: Mature teratoma of the spinal cord in adults is extremely rare occurrence. However, this diagnosis should be kept in mind when evaluating a cystic lesion of cord even in adults. Maximal safe resection of the lesion results in prolonged deficit-free survival.

Introduction: The covering of spinal cord is same as that of brain. The pia mater, arachnoid and dura mater covers the spinal cord from inside out. The pia mater extends from cephalic end of spinal cord up to terminal portion i.e., conus medullaris. Beyond the conus, the pia mater extends in the form of filum terminale. The filum terminale extends beyond the conus medullaris and attaches upto dorsal aspects of coccyx to stabilise the spinal cord in its position. Aim: To study the length of filum terminale in the foetuses of third trimester gestational age. Materials and Methods: The present cross-sectional observational study was carried out in 30 foetuses collected from museum of Department of Anatomy and Department of Obstetrics and Gynaecology. The permission and approval from University Ethical Committee was taken before starting the study. The foetuses were divided into three groups taking into consideration their gestational age (four foetuses in 1st group 28-31 weeks, 12 foetuses in 2nd group 32-35 weeks and 14 foetuses were in 3rd group 36-40 weeks gestational age). Also, the gender-wise variation (11 male and 19 female foetuses) was taken into account. All the data were recorded in Microsoft excel sheet and Statistical Package for the Social Sciences (SPSS) 23.0 software was used for statistical analysis. Numerical values were reported as the mean±standard deviation. Results: In this study, the mean length of filum terminale was 4.35±1.04 cm with range minimum 2.31 cm to maximum 5.90 cm. The length of spinal cord and length of filum terminale measurements significantly increased with increasing gestational age (p<0.001). The length of spinal cord, length of filum terminale measurement and ratio of length of filum terminale to length of spinal cord (FT/SC) were significantly higher in male foetuses (p<0.05). Conclusion: The association between gestational age (weeks), length of filum terminale, and length of spinal cord among all foetuses, and male and female separately were statistically significant. [ABSTRACT FROM AUTHOR]

Background: Renal cell carcinoma (RCC), the most common kidney cancer, often metastasizes to bones, lungs, liver, and the central nervous system. Intramedullary spinal metastasis from RCC is rare but can cause significant neurological deficits, necessitating prompt diagnosis and treatment through surgical intervention, radiotherapy, and immunotherapy., Observations: An 86-year-old man presented with progressive right lower-limb weakness and reduced sensation over 3 weeks. His medical history included a right nephrectomy for RCC 15 years earlier and L4-S1 spondylosis. Imaging identified a bleeding lesion in the conus medullaris at T11-12 and an incidental left kidney mass. Urgent surgical exploration led to a T12 laminectomy and en bloc removal of the lesion, which was confirmed as RCC metastasis. Postoperatively, the patient received focused radiotherapy and immunotherapy, showing significant motor and sensory improvement before dying 3 months later., Lessons: This case underscores the importance of comprehensive diagnostic imaging for the accurate identification and characterization of spinal lesions. An interdisciplinary approach involving neurosurgeons, oncologists, radiologists, and pathologists is crucial for optimal treatment planning. Urgent surgical intervention can effectively address acute neurological deficits caused by intramedullary lesions. Additionally, adhering to postoperative care instructions, such as deep venous thrombosis prophylaxis, is vital to prevent fatal complications. https://thejns.org/doi/10.3171/CASE24349.

We report a case of a 40-year-old female patient admitted to the hospital due to lumbar pain that spread to both legs and was associated with weakness of the lower extremities. Magnetic resonance imaging revealed an intradural - extramedullary tumor at the level of the T12 - L2 vertebra. The lesion was over 7 cm in greatest diameter and compressed the conus medullaris. The patient underwent surgery to remove the entire tumor. Postoperative pathology confirmed the diagnosis of schwannoma. The symptoms resolved almost completely without significant complications.

Introduction: The covering of spinal cord is same as that of brain. The pia mater, arachnoid and dura mater covers the spinal cord from inside out. The pia mater extends from cephalic end of spinal cord upto terminal portion i.e., conus medullaris. Beyond the conus, the pia mater extends in the form of filum terminale. The filum terminale extends beyond the conus medullaris and attaches upto dorsal aspects of coccyx to stabilise the spinal cord in its position. Aim: To study the length of filum terminale in the foetuses of third trimester gestational age. Materials and Methods: The present cross-sectional observational study was carried out in 30 foetuses collected from museum of Department of Anatomy and Department of Obstetrics and Gynaecology. The permission and approval from University Ethical Committee was taken before starting the study. The foetuses were divided into three groups taking into consideration their gestational age (four foetuses in 1st group 28-31 weeks, 12 foetuses in 2nd group 32-35 weeks and 14 foetuses were in 3rd group 36-40 weeks gestational age). Also, the gender-wise variation (11 male and 19 female foetuses) was taken into account. All the data were recorded in Microsoft excel sheet and Statistical Package for the Social Sciences (SPSS) 23.0 software was used for statistical analysis. Numerical values were reported as the mean±standard deviation. Results: In this study, the mean length of filum terminale was 4.35±1.04 cm with range minimum 2.31 cm to maximum 5.90 cm. The length of spinal cord and length of filum terminale measurements significantly increased with increasing gestational age (p

Purpose: Although spinal cord stimulation (SCS) is a safe procedure, equipment-related, biological and neurological complications have been observed in previous research, particularly case reports. No reports of new neuropathic pain in the absence of neurological deficit or positive MRI findings have been described. We detail three cases of new-onset radicular pain in the L5/S1 dermatome following insertion of SCS. Methods: This was a retrospective case series of three patients. Details of clinical background, indications for SCS and events occurring during insertion and further management were recorded. Results: All three cases were technically difficult and required multiple epidural entry levels, with repeated passage of the electrode into and within the epidural space. All cases involved accessing epidural space T12/L1 and L1/L2. A possible explanation for the new-onset radicular pain could concern oedema to the conus medullaris, resulting from repeated passage of the electrode at the T12/L1 level. Alternative explanations could be direct trauma to transiting nerve roots, neuroplastic changes resulting in peripheral and central sensitisation and immune-mediated nerve injury. Conclusion: MRI imaging should be analysed prior to the SCS procedure to identify the level of the conus medullaris, with the aim of avoiding repeated passage of electrodes at that level. Unintended neurological adverse events should be discussed with patients during the consent process. Careful patient selection and psychological screening may also help identify patients who may be unlikely to respond to SCS therapy. Further reporting of new radiculopathic pain following SCS insertion is required to strengthen understanding of its potential causes. [ABSTRACT FROM AUTHOR]

Low-grade, sporadic, pilocytic astrocytomas (PAs) are rare spinal cord tumors diagnosed in adult patients. Their localization to the conus medullaris is exceedingly rare, having only been described in a limited number of case reports. Here, we describe a case of a 22-year-old female presenting with back pain, lower extremity weakness, hypoesthesia, and urinary incontinence. Imaging studies demonstrated a cystic lesion of the conus medullaris that was treated with subtotal resection and cyst-subarachnoid shunt placement. Final pathology report confirmed PA from the histology of surgical specimens. We discuss the current literature of conus medullaris lesions and their differential diagnosis. [ABSTRACT FROM AUTHOR]

Presence of the artery of Desproges-Gotteron is extremely rare. It has seldom been mentioned in the literature as well. The authors have dealt with a case of a dural arteriovenous malformation (AVM ) of conus medullaris fed by the artery of Desproges-Gotteron in a young female of 19 years. The patient presented with a tingling sensation of lower limbs, progressive difficulty walking, and incontinence of the bladder. There was weakness in all groups of muscle of both lower limbs and definite sensory level on examination. Magnetic resonance imaging revealed multiple flow voids at the level of conus medullaris. Spinal digital subtraction angiography (DSA) revealed dural AVM at the level of conus. The patient underwent transarterial embolization with 30% Endocryl( n -butyl cyanoacrylate) in two stages, and repeated spinal DSA revealed no evidence of residual AVM. Patient's neurology gradually improved. Almost 2 years down the line, the follow-up revealed gradual but complete motor and sensory deficits recovery except for occasional burning pain in lower limbs. Spinal AVM supplied by the artery of Desproges-Gotteron is a unique variation. Moreover, the authors believe that it is the first reported case in Bangladesh. [ABSTRACT FROM AUTHOR]

Background and Importance: Spinal Subdural Hematoma (SSH) is a rare condition with an unknown incidence in the general population. Iatrogenic spinal subdural hematoma radiologically mimicking a prolapsed dorsolumbar disc has not been published in the literature. Case Presentation: A 65-year-old female presented with altered sensorium and generalized weakness for 3 days evaluated by a neurologist who diagnosed it as a metabolic encephalopathy with Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) with severe anemia and hypothyroidism. She underwent a diagnostic lumbar puncture and following which, within 24 hours, she developed weakness of both the lower limbs. MRI of dorsolumbar spine was done which revealed D12-L1 extruded disc causing severe compression to the conus medullaris with D12-L2 subarachnoid lesion and cord edema. On opening the dura, a large organized hematoma on the anterior aspect of the conus was seen and evacuated. Conclusion: Spinal subdural hematoma presents with a spectrum of signs and symptoms. Although MRI is the investigation of choice but SSH presenting like a prolapsed intervertebral disc on MRI is one of its kinds and should be kept in mind since it carries a grave prognosis if not treated early with emergency decompression.