Meningocele and Tethered Cord

H&P

• HPI: low back meningocele found at birth at an OSH
• PE:
  • FOC 33.2 cm
  • Fontanelle flat and soft
  • Low back midline protuberant mass
  • Transilluminates well
  • Intact skin without CSF leak
  • Full strength bilateral lower extremites
  • Normal tones
  • +Babinski’s bilaterally
• Workup: neuraxis MRI without contrast

Imaging

C/T/L Spine MRI w/o Contrast - Sagittal T1WI/T2WI/T2WI and Axial T2WI

Lumbar Spine MRI w/o Contrast - Sagittal T1WI/T2WI and Axial T1WI/T2WI

The conus terminalis was tethered by a fatty filum and terminates at the upper L4 level.

Brain MRI w/o Contrast - Axial T1WI/T2WI and Sagittal T1WI

There is no hydrocephalus or Chiari malformation on the brain MRI.

Differential Diagnosis

• 2-3 cm simple meningocele without accompanying hydrocephalus or Chiari malformation
• Fatty filum with tethered spinal cord
• Myelomeningocele

Surgical Intervention

• Intraoperative neuro-monitoring
• Prone
• Head on a donut
• Vertical incision, ellipsing out the meningocele
• Dissection around the meningocele
• Circumferential freeing of the arachnoid
• Creation of dural plane
• Identification of fatty filum
• Stimulation of fatty filum without response at 3 mA
• Cauterization of fatty filum at above and below, 15 mm apart
• Removal of fatty filum and sent for permanent pathology
• Retraction of the cephalad end of the fatty filum superiorly (out of view)
• Closure of dura (4-0 Nurolon) - watertight, no leak on Valsalva
• Closure of muscle layer (3-0 Vicryl)
• Closure of skin (4-0 Vicryl Rapide)

Intraoperative Imaging

The dura layer was identified.

Specimen: fatty filum.

Post-operative Course

• Back to NICU
• No new deficits
• Wound remained dry
• Discharged on POD1