Pediatr Radiol (1989) 19:442-443
Radiology
Short reports
MRI in the evaluation of spina bifida patients in the
remote period after meningomyelocele repair*
M. R. Williamson t, C. M. Glasier 2, W. M. Chadduck 3, E.J.C. Angtuaco 4 and E. F. Binet 5
1 University of New Mexico School of Medicine, Albuquerque, New Mexico, 2, 3 Arkansas Children's Hospital,
4 University of Arkansas for Medical Sciences, Arkansas, and 5 Medical College of Georgia, Georgia, USA
Abstract. MRI was performed on 22 patients ranging
in age from 3 months to 16 years who had closure of
their meningomyelocele shortly after birth. These
patients had developed new clinical findings sugges-
tive of spinal cord dysfunction. MRI showed low
placement of the spinal cord in all 22. Six patients
had lipomas, five had diastematomyelia and six had
hydromyelia. Four patients had an obviously dys-
plastic terminal cord.
Almost all spina bifica patients undergo surgical clo-
sure of their defect shortly after birth, but must be fol-
lowed for ongoing problems of urinary or fecal incon-
tinence, kyphoscoliosis, foot deformities and hip
dislocation; neurological problems ,including hy-
drocephalus~ and sensory-motor disabilities also
occur.
Various forms of tethering or cavitation of the
spinal cord may be associated with such progression
of neurological dysfunction or scoliosis. In the past,
many of these patients required myeIography; re-
cently MRI of the spine has been used to evaluate
spina bifida patients concurrent with routine neuro-
logic and orthopedic follow up.
The purpose of this paper is to demonstrate the
advantages and limitations of MRI scanning as the
definitive imaging, procedure for the management of
complex spina bifida problems including determin-
ing the level of the conus medullaris, detection of
mass lesions such as a lipoma, diastematomyelia,
syringomyelia or hydromyelia and to identify the
thickness of the filum terminale.
Materials and methods
Twenty two patients are included in this study, ranging in age
from three months to sixteen years with nineteen between the ages
* Work done at University of Arkansas for Medical Sciences and
Arkansas Children's Hospital, Arkansas, USA
Pediatric
© Springer-Verlag 1989
of two and ten. They all had bowel or bladder incontinence, neu-
rological abnormalities, scoliosis or other orthopedic problems.
Out patient examinations were routinely performed. Sedation was
usually required for patients under 6 years. For the first six months
of the study, examinations were obtained on a 0.6T Technicare
magnet. More recently a 1.5 GE Signa System was used in con-
function with a five inch surface coil. Small infants were examined
utilizing the head coil. Tl-weighted images were obtained
(TR = 800 ms, TE = 20 ms), with a slice thickness of either 3 mm or
5 mm with a 20% gap. Proton density axial images were obtained
from below to above the conus medullaris. The area adjacent to
the spina bifida was imaged to identify adherence of the spinal
cord to dysplastic tissue or scar at the site of the previous surgical
repair. Coronal imaging was utilized when a diastematomyelia
was suspected or identified. Where hydromyelia or syringomyelia
were present, the most cephalad extent of the lesion was imaged.
T2-weighted images (TR = 2000, TE = 80) helped to differentiate a
syrinx from the fibrous or bony tissue of a diastematomyelia.
Results
All twenty two patients had a low lying conus medul-
laris located below the L2-3 level (Fig. 1); the conus
was posteriorly located and adjacent to the surgically
repaired defect. Six of the patients had lipomas near
the terminal portion of the spinal cord (Fig. 2). Three
patients had abundant epidural fat but the MRI was
inconclusive as to whether or not the fat extended into
the intradural space. Diastematomyelia was present
in five patients. In one patient, both diastematomyelia
and syringomyelia were present (Fig. 3). T2 weighted
axial images demonstrated that the upper portion of
this cord was involved by hydromyelia. Four patients
had a dysplastic terminal spinal cord which could not
be further classified. Severe scoliosis compromised
the examination in three patients but diagnostic infor-
mation was still obtained.
Discussion
In all 22 patients the information obtained from
MRI studies obviated the need for additional radio-
graphic procedures. The extent and localization of
M. R. Williamson et al.: Spina bifida 443

L
L3 D H D X L

L D
L4 D
DYS
DYS

Fig. 1. Summary findings. X= Low lying

L5 H L
H
X X
cord without other abnormality, L= Lipo-
ma, ?L= Abundant fat with questionable
$1 L X L H X
lipoma, D = Diastematomyelia, H= Hy-
Lower DYS ?L ?L
H DYS ?L
dromyelia, DYS= Obviously dysplasic ter-
Sacrum o . . . . . . . , o . . . . . . . , . . . . minal cord
Case: I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Fig.2. T1 weighted image. This lipoma (arrow) penetrates the the- does appear to be present, the decision to operate is
cae still based on clinical symptoms.
Fig.3. TI weighted image. The lower portion of the cord is split The incidental finding of a syringomyelia in a
(arrowhead). The upper cord is involved by hydromyelia (arrow) spina bifida patient is not an indication for surgical
treatment without correlative neurological findings.
Decompression would be considered in the presence
the lipoma, diastematomyelias or hydromyelias were
of progressive neurological deficits. Because of the
shown with a greater degree of certainty on M R than
restricted resolution of the MRI device, the ilium ter-
on any other study. minale could not be consistently imaged. While this
The patients in this study presented with new
would be a limitation in a p r i m a ~ tethered cord syn-
clinical problems months to years following surgical
drome, the patients presented here were known to
closure of a myelomeningocele. In the past these pa-
have a disorder in which the cord is low.
tients would have required myelography and/or CT
and most would have needed hospitalization.
A secondary tethered cord syndrome occurs References
when the low position of the conus medullaris results 1. Fitz CR, Harwood-Nash DC (1975) The tethered conus. AJR
from its attachment to a lipoma, diastematomyelia, 125:515-523
or mass of dysplastic tissue or scarring at the site of 2. Heinz ER, RosenbaumAE, ScarffTB, etal. (1979) Tethered
spinal cord following meningomyelocele repair. Radiology
the meningomyelocele repair [1-4]. A criticism of 131 : 153-160
MRI in our patients might be that we were unable to 3. Hoffman HJ, Hendrick EG, Hurnphreys RP (1976) The teth-
further delineate the nature of the fat in three of our ered spinal cord: its protean manifestations, diagnosis, and sur-
patients. It is possible that CT might have been able gical correction. Child Brain 2:145-155
to depict whether the fat was extending into the in- 4. Bruce DA, Schult L (1979) Spinal lipomas in infancy and child-
hood. Child Brain 5:192-203
tradural space and, therefore, was a cause of re-
tethering. The depiction of the dysplastic terminal Received: 17 August 1987; accepted: 25 February 1988
cord in four patients was vastly superior to any im-
ages we have seen with either CT or ultrasound. We Dr. M. R. Williamson
University of New Mexico School of Medicine
could not tell whether or not the cord had primary or Department of Radiology
secondary tethering due to scar at the site of the pre- Albuquerque, NM 87131
vious repair. However, even if re-tethering to the scar USA