0:00

So the good news is the vast majority

0:02

of times screening neonatal spinal ultrasounds are going

0:05

to be normal again,

0:06

because in our practice we image a bunch

0:09

of simple sacral dimples, which have a low association

0:12

with spinal dys racisms, but we do encounter abnormalities.

0:16

So let's look at some of those.

0:18

So this is an, an an infant who had dilation

0:21

of the central append al spinal canal,

0:23

but this is larger than four millimeters in diameter.

0:27

Um, this one is still within two centimeters of length,

0:30

but this is hydro of the conus mellis.

0:33

So this is abnormal enlargement

0:35

of the central append al spinal canal,

0:38

also called a focal snx.

0:40

In the conus meis there are associations

0:43

with Chiari two malformation and split cord malformation.

0:47

So make sure that you pay close attention

0:49

to other abnormalities that you may encounter.

0:51

Uh, at ultrasound, the vast majority of patients

0:54

where we find something abnormal on ultrasound will go on

0:58

to MRI for better evaluation

1:00

and potentially pre-surgical planning.

1:03

So, um, don't freak out if you can't see well

1:06

or if you're having a difficulty classifying the abnormality

1:10

that you're seeing with ultrasound

1:11

because you'll recommend an an MRI

1:13

for additional characterization

1:15

of the ultrasound abnormalities.

1:18

Another example of an abnormality is

1:21

split cord malformation.

1:22

So I love that they have changed the name from diastema my

1:27

to split cord malformation because it's easier to say.

1:30

So this is where you have two cords

1:32

that are either completely separated or partially separated

1:36

and on ultrasound, I think a transverse cinematic image is

1:39

where you can make this, uh, diagnosis the easiest.

1:42

You'll be able to see two separate spinal append canals.

1:46

So that's what these purple arrows here,

1:48

I don't have an axial T one, uh, MRI comparison to show you,

1:52

but you'll see this, uh,

1:53

this like cleft either completely separating the two cords

1:57

or partially separating the two cords between.

2:00

There are two subtypes where you either do

2:03

or do not have a bony cleft

2:05

or a cartilaginous cleft separating the two uh, hemi cords.

2:10

Um, and here's your uh, MRI example

2:12

where on this coronal T two plan, you can see portions

2:15

of two separate, uh, central penal canals here.

2:19

And for me, I think the sagal is really challenging to tell

2:23

that there are partially split cords here

2:25

because the money is really the axial plane.

2:27

So make sure you don't just look at your sagittal images on

2:31

your ultrasound or MRI obviously, but look at the transverse

2:34

or axial plane two.

2:35

That's where you're gonna be able to tell

2:36

that it's partially or uh, in completely two chords.

2:41

The next thing I wanna show you is

2:42

coddle regression syndrome.

2:43

So remember that your, uh, conus mellis should be nice

2:47

and triangular shaped.

2:49

Um, usually when we're doing a spinal ultrasound,

2:52

we're worried about a cord being too low,

2:55

but this is one of the examples

2:56

that the cord can be too high and

2:58

Again, it's gonna have that rounded

3:00

or blunted appearance of the conus.

3:02

Meis not a triangular shape,

3:04

but it's gonna look like a chopped off inferior aspect

3:06

of the cord or a blunted inferior aspect of the cord.

3:09

So you can have a normal position of the conus meis

3:12

or it can be too high in position.

3:15

Um, there are some associations with, um, infants

3:18

of diabetic mothers.

3:20

You can have a variable spectrum

3:22

of coddle regression syndrome

3:24

where you will also have variably absent

3:27

or fused, uh, lumbosacral os osteo structures

3:32

and pelvic structures.

3:33

So this is another example

3:35

where the sonographer put a body marker to be able

3:37

to help us see that this conus mellis is not at the level

3:40

of the lumbar spine, but it's at the level

3:41

of thoracic spine.

3:43

This infant had not only an x-ray where you can see absence

3:46

of the, uh, vertebral bodies

3:48

and uh, OSS osteo structures of the lumbar spine

3:52

and sacral spine as well as we're missing the,

3:55

the sacrum here completely.

3:57

And here's the uh, MRI comparison

3:59

where you can see this is an abnormally high termination

4:02

position of the conus mellis at the T

4:04

seven vertebral body level.

4:06

And it has an abnormal rounded morphology rather than

4:08

that nice triangular shape morphology.

4:11

So this is coddle regression syndrome.

4:14

Another example of an etiology of tethered cord is, um,

4:18

this was an infant who had cutaneous infantile hemangiomas.

4:22

We screen these patients for neonatal spine ultrasounds

4:26

because the, if the, uh,

4:27

hemangioma has deeper extension into the spinal canal,

4:31

there can be a secondary tethering of the spinal cord.

4:35

So this is an example where we could see on color doppler

4:38

imaging a classic appearance

4:39

of a cutaneous infantile hemangioma

4:42

with a marked hyper vascularity.

4:45

I haven't shown you a color doppler or power doppler image,

4:47

but on the spectral image you can see

4:49

that it is very hypervascular

4:51

and it has this characteristic low resistance arterial

4:54

waveforms in the infantile Haman itself.

4:58

On this gray scale element, you can see the infantile Haman

5:00

genome and the subcutaneous soft tissues

5:03

and you see it tracking all the way down to the level

5:05

of the conus midis, which is low lying.

5:08

How can we tell what level we are at?

5:09

This is going to be S one. This is L five.

5:12

So that lumbosacral junction prominence is the

5:15

five S one junction.

5:17

And so this, um, conus mellis extends all the way

5:20

to the superior inflate of L five.

5:22

So this is a low line conus mellis concerning

5:25

for tethered cord secondary to this infantile heman.

5:29

And this is a T two weighted MRI

5:31

that's showing you similar abnormalities.

5:33

I have rotated it so that it looks just like our ultrasound

5:36

where you see this ill-defined T two uh,

5:39

intermediate or low signal.

5:41

Um, hemangioma, you can see it tracking down

5:44

to the inferior aspect

5:45

of the conus mellis which is stuck up here at the posterior

5:49

aspect of the cord where that hege makes sense.

5:52

Intramedullary, one of our last example is

5:56

Gonna be a sacro coil teratoma.

5:58

So this infant uh, had some abnormalities on exam

6:02

where they are looking to see if there is uh,

6:05

associated cord abnormalities

6:07

or what other associations are there

6:09

with this sacro coital mass or presacral mass.

6:12

So this radiographic is showing you there's this abnormal

6:15

soft tissue fullness at the uh, inferior aspect

6:19

of the sacrum involving the coys.

6:21

You can see this is primarily a cystic looking mass,

6:24

but there are some solid components.

6:26

It's very heterogeneous in appearance

6:28

with this dominant cystic component

6:29

and it's at the inferior aspect of the uh, sacrum

6:33

and involving the coys.

6:35

The good news is in this infant I love this image

6:38

because the tech not only gave us the lumbosacral junction,

6:41

so we can tell this is L five, L four,

6:43

L three, L two, L one.

6:44

So this conus MedU terminates at a normal level at the L one

6:48

vertebral body um, level.

6:50

Of course this infant is going to go on to um, MRI

6:54

for preoperative planning,

6:55

but um, we could diagnose the spinal canal contents

6:59

and get a better look at that presacral mass in this infant.

7:04

Last but not least, you might encounter, uh, hematoma

7:07

after lumbar puncture.

7:09

So after a failed uh, lumbar puncture attempt,

7:12

you can see blood in the dorsal aspect.

7:15

It's almost always extradural in location.

7:18

Um, so either in the subdural space

7:20

or epidural space, these arrows are pointing to

7:23

that abnormal genic blood post lp.

7:26

We do see some normal CSF anterior to that hemorrhage

7:30

and then conus mellis

7:31

and nerve rootlets are sort of compressed anteriorly

7:34

by this um, extradural heterogeneous, uh, post LP blood.

7:40

So in conclusion we do tons

7:42

of screening neonatal spine ultrasounds, um,

7:45

because we can see prior to fusion

7:47

of the posterior elements.

7:49

Um, if you look at the uh, practice parameters

7:52

through the A-C-R-A-I-U-M-S-R-U

7:55

and SPR, the the joint practice parameters, um, they say

7:59

that you can see through up to six months of age.

8:01

Realistically in our practice we can see well uh, up

8:04

to four months of age after four months

8:07

of age we will still try to see what we can see sonographic,

8:10

but um, we just let the parents

8:12

and providers know that that patient might still need

8:15

to go on to MRI to be able to see adequately.

8:18

Um, you just might not be familiar with

8:20

what the ultrasound appearance of the, uh,

8:22

neonatal spine looks like at ultrasound compared to MRI,

8:26

but it's the same dang things that you can see.

8:28

But you get to see motion with ultrasound

8:30

because you have some cinematic images

8:31

that you can acquire without a concern

8:34

for increasing radiation or sedation time.

8:37

And then it's important to know when you should refer on

8:39

to MRI and what you can say.

8:40

Nope, that's just normal variant.

8:42

No need to go on to anything else or refer to neurosurgery.

8:46

So now let's go into some cases to review examples

8:49

of abnormal.