1. Neonatal Spine
Tanya Nolan

2. Embryology Ectoderm Mesoderm
Neural tube arises from ectodermal cells and becomes the spinal cord and brain.
Mesoderm
Forms bony spine, meninges, and muscle

3. Embryology
Defects of the spine occur in the first 8.5 wks of life as the fetal nervous system develops
Incomplete seperation of the neural tube from the ectoderm
Cord tethering, Diastematomyelia, or a Dermal sinus
Premature Seperation
Lipomas
Failure of neural tube to fold and fuse in the midline
Myelomeningocele
Disorders of distal cord
Fibrolipomas of the filum terminale

4. Anatomy Vertebral Column
Houses spinal cord, spinal nerve roots, and meninges
Total 33 Vertebrae
7 Cervical
12 Thoracic
5 Lumbar
5 Sacral
4 Coccygeal

5. Spinal Cord Cylindrical, grayish white structure Meninges Dura Mater
Outer strong, dense, fibrous sheet
Arachnoid Mater
Middle layer
Subarachnoid Space: Filled with cerebral spinal fluid.
Pia Mater
Inner vascular layer

6. Spinal Cord Begins Terminates
Above the formamen magnum and is continuous with the medulla oblongata
Terminates
Adult: Lower border of L1
Child: Upper border of L3

7. Spinal Cord Conis Medularis Filum Terminale Cauda Equina
Inferiorly cord tapers to a point
Filum Terminale
Prolongation of pia matter that is attached to the coccyx
Cauda Equina
“Horse tail”
Lower nerve roots

8. Nerve Roots
31 Pair
Carries impuses to and from the brain to the rest of the body.

9. Indications for Sonographic Examination
Midline Cutaneous Abnormality
Sacral Dimple
Deep
Asymmetric
Suspicious if more than 1 inch from anus
Hemangioma
Raised midline
Hairy Patch
Tail-like projection of lower spine
Diagnosis of myelomeningocele or myeloschisis
Lower extremity deformity

10. Sonographic Technique
Patient Position
Prone
Spine flexed (seperates posterior elements)
Lateral Decubitus
Upright
Transducer
High frequency linear array
Possible stand off pad

11. Sonographic Technique
Where do you begin?
1) Sacral area & count stepwise ascent of sacral vertebral elements
2) Count from lowest rib bearing vertebra (rib over kidney & follow medially)
Determine level of Conus Medullaris!!!

12. Sonographic Appearance
Vertebral Bodies
Echogenic; anterior
Lamina
Slighly off midline; “Overlapping Roof Tiles”
Spinous Processes
Inverted “U”s
Coccyx
Hypoechoic, do not mistake for a fluid collection.
Spinal Cord
Hypoechoic with slightly echogenic borders and an echogenic line extending along its middle.
Nerve Roots
Echogenic
Move and change configuration during respiratory variations.
Conus Medullaris
Normally above endplate of L3; Most cords end above L2. (Most tethered cords are unquestionably low.)

13. Sonographic Appearance Sagittal View
Anterior echogenic body surface; posterior dorsal spinal elements.
1. Posterior elements or spinous processes
2. posterior arachnoid-dural layer bordering spinal canal
3. subarachnoid space filled with cerebrospinal fluid
4 posterior margin of the spinal cord
5. spinal cord with central echo complex
6. Anterior margin of the spinal cord

14. Sonographic Appearance Level of the Conus – Sagittal View
Tapered conus medullaris shows the end of the spinal cord.
1. Posterior elements or spinous processes
2. cauda medullaris
3. filum terminale
4. cauda equina and nerve roots.

15. Sonographic Appearance Level of the Conus – Transverse View
Nerve roots are echogenic as they surround the spinal cord.
1. Paravertebral muscles
2. Laminae of vertebral arches
3. subarachnoid space filled with cerebrospinal fluid
4. spinal cord with central echo complex
5. paired dorsal and ventral nerve roots
6. vertebral body.

16. Pathology

17. Tethered Cord Fixation of cord @ caudal location (below L3)
Diminished cord movement.
Cord mechanical stretching, distortion, and ischemia with growth and activity. TC L

18. Tethered Cord Sonographic Findings
Visualization of cord caudal to normal termination
Diminished cord pulsation
Eccentric cord location with the canal
Intradural lipoma and tethered cord in 2-week-old girl with hairy patch on lower back. Longitudinal sonogram reveals typical features of hyperechoic lipoma (calipers) attached to dorsal aspect of thoracolumbar spinal cord. Conus is tethered to mass at L3-L4 disk space.

19. Lipoma Mass of filum terminale
Continuous with subcutaneous tissues & presents as a fatty back lump.
Frequently associated with tethered cord.
Sonographic Finding
Echogenic Mass

20. Hydromelia Dilation of central canal
Diffuse or focal
Associated with myelomeningocele and diastemotomyelia
May mimic or co-exist with syringomyelia
Sonographic Findings
Separation of echogenic linear structures of central canal.
Hydromyelia in a 1-month-old infant in whom lumbar myelomeningocele and thoracic hydromyelia were noted on the 1st day of life. Sagittal US scan shows a dilated central canal (arrows).

21. Diastamatomyelia Cord is split at one or more sites by a septum
Assoiated with meningocele or myelomeningocele
Vertebral column abnormal on plain radiography
Sonographic Findings
Split segments best seen in transverse views
Transverse scan of the lumbar spinal canal shows left and right hemicords. Each hemicord has an eccentric central canal

22. Cysts on Spinal Cord May be seen in cauda equine or filum terminale
Small cysts in filum terminale may be remnants of a terminal ventricle or an arachnoid pseudocyst
Related to Tethered Cord

23. Myelomeningocele Spina Bifida
Low termination of spinal cord
Protruding pouch containing CSF and nerves
Sonographic Findings
Pre-op exams can differentiate between myelomeningocele and meningocele
Flat nontubulated cord with nerve roots extending into the defect.

24. Dermal Sinus Tract
Small dimple-like opening in the midline of the spine connecting deep into the spinal cord.
The majority located at the level of the sacrum or the lumbar region.
Communication with spinal canal contents increases possibility of meningitis
Attaches to the end of the spinal cord, causing tethering.
Sonographic Findings
Easily followed if fluid filled or disrupts normal soft tissue planes
Dural penetration is difficut to ascertain or exclude on sonography