Use of the Prone Position in the MRI Evaluation of Spinal Cord Retethering

Vernet, Olivier; O’Gorman, Augustin M.; Farmer, Jean‐Pierre; McPhillips, Maeve; Montes, José L.

doi:10.1159/000121142

Cited by 37 publications

(25 citation statements)

References 11 publications

(12 reference statements)

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Section: Discussionmentioning

confidence: 99%

“…Many factors associated with neuraxial anaesthesia have been studied including the structures at the level of the termination of the spinal cord and dural sac [11], vertebral level and shape of the conus medullaris [12], shape of the epidural space [13][14][15], and distance from the skin to the epidural or subarachnoid spaces [16][17][18][19]. However, the effect of body position relevant to neuraxial blockade has not been well studied [20][21][22][23][24], especially in children.Ultrasonography, which is a well-established method of investigating the spinal canal, spinal cord, and meningeal coverings in infants and children, has the advantage of being real time, non invasive and safe [25][26][27]. It allows detection of congenital malformations such as myelocele, myelomeningocele, spinal lipoma, dorsal dermal sinus, tight filum terminale syndrome, diastematomyelia, hydromyelia and syringomyelia.…”

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confidence: 99%

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The effect of flexion on the level of termination of the dural sac in paediatric patients

et al. 2009

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SummaryAlthough the anatomy of the spinal cord and its associated structures have been well defined, the effects of body position relevant to neuraxial blockade have not been elucidated. This study was designed to determine the effect of body position on the end of the dural sac in children. After induction of anaesthesia, ultrasound examination was performed to evaluate the location of the dural sac end in the lateral position with a straight back and knee, and in the lateral position with the knees, legs, and neck flexed. The level of the end of the dural sac was determined in relation to the vertebrae. Our data demonstrate that the dural sac shifts significantly cephalad in the lateral flexed position used for neuraxial blockade (p < 0.001). These results suggest that the safety margin to avoid dural puncture during hiatal or S2-3 approach for caudal block can be increased in younger children. Dural puncture is a serious technical complication during single-shot caudal block, which is the most common regional technique for postoperative analgesia for paediatric subumbilical surgery. The prevalence of dural puncture associated with caudal analgesia is relatively low. It has only been shown in several case reports [1,2] or at a rate of 1.2% in previous large-scale studies [3,4]. In the study of 760 children, Busoni did not find any case of dural puncture and Dalens [5] reported only one dural puncture in his series of 750 paediatric caudals. Sometimes it is difficult to identify the sacral hiatus and the caudal space due to variations of anatomical structures or obesity. In these cases, a trans-sacral approach to caudal block, described by Busoni [6], may be used as an alternative method. Although no dural puncture was reported in several trans-sacral approach studies [6][7][8], the risk of dural puncture is a possibility. It is known that the end of the dural sac is located at the S4 level just after birth, then ascends to the S2 level as the child grows [9].The anatomy of the spinal cord and its associated structures have been well defined [10], largely based on post-mortem or imaging studies in the supine or prone positions. Many factors associated with neuraxial anaesthesia have been studied including the structures at the level of the termination of the spinal cord and dural sac [11], vertebral level and shape of the conus medullaris [12], shape of the epidural space [13][14][15], and distance from the skin to the epidural or subarachnoid spaces [16][17][18][19]. However, the effect of body position relevant to neuraxial blockade has not been well studied [20][21][22][23][24], especially in children.Ultrasonography, which is a well-established method of investigating the spinal canal, spinal cord, and meningeal coverings in infants and children, has the advantage of being real time, non invasive and safe [25][26][27]. It allows detection of congenital malformations such as myelocele, myelomeningocele, spinal lipoma, dorsal dermal sinus, tight filum terminale syndrome, diastematomyelia, hydromyelia and syri...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

The effect of flexion on the level of termination of the dural sac in paediatric patients

et al. 2009

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“…In a cadaver study of adults without a history of TCS, 10% of patients had a filum terminale >2 mm when measured at their initial points[ 34]. Attempts have been made at using MRI in both the prone and supine position, in order to determine whether tethering is resulting in decreased cord motion[ 35, 36]. The utility of prone MRI for diagnosing TCS has yet to be validated and is not widely used.…”

Section: Diagnosismentioning

confidence: 99%

Tethered Cord Syndrome: An Updated Review

2007

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Tethered cord syndrome (TCS) is a diverse clinical entity characterized by symptoms and signs which are caused by excessive tension on the spinal cord. The majority of cases are related to spinal dysraphism. TCS can present in any age group, and presentations differ according to the underlying pathologic condition and age, with pain, cutaneous signs, orthopedic deformities and neurological deficits being the most common. Surgical untethering is indicated in patients with progressive or new onset symptomatology attributable to TCS. The surgical strategy aims to release the tethering structure and thus the chronic tension on the cord. Early operative intervention is associated with improved outcomes. Pain relief is accomplished in almost all cases. Realistic surgical goals include relief of pain and stabilization of neurological function, although improvement in function is often seen. Cord untethering can also halt the progression of scoliosis. The benefits of surgery are debated in asymptomatic patients and patients with normal imaging.

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“…Performing MRI in different body positions has been evaluated to facilitate diagnosing occult TCS in people. Decreased spinal cord motion between the prone and supine position has been considered suggestive for TCS 15, 17. The dog presented here, recovered completely after surgical transection of the filum terminale.…”

mentioning

confidence: 56%

“…In contrast to TCS associated with more complex vertebral malformations, such as spina bifida, transection of a thickened filum terminale is considered a technically straightforward procedure associated with a low postoperative morbidity and good prognosis for recovery. Rethetering with recurrence of clinical signs, caused by arachnoid adhesions, has been reported in a small proportion of surgically treated cases 16, 17, 18, 19, 20…”

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confidence: 99%