0:00

So we're moving from the head, from head to toe.

0:03

Now we're gonna cover, uh, the spine.

0:06

So infants, we are able to image with ultrasound.

0:10

And so this is primarily gonna be focused on

0:12

spine ultrasound.

0:14

It's a screening modality.

0:15

And then those patients who are abnormal

0:18

or who have continued concern clinically will go on to MRI.

0:22

But let's focus on a spine ultrasound.

0:25

And one of my former trainees renamed this talk baby got

0:28

back and I am gonna still call it that.

0:31

So for this part of this review,

0:33

we're gonna talk about indications for, uh,

0:35

screening spine ultrasounds, how to acquire the images.

0:40

We're gonna review normal anatomy including normal variants,

0:44

and then we'll end with a few abnormal cases

0:46

before we get into the cases

0:47

that you can scroll through yourself.

0:50

So, indications for neonatal spine imaging are anybody

0:54

that they're concerned might have an occult

0:56

spinal dysraphism.

0:58

So something wrong with dysraphism just means bad seam

1:02

or bad zipper I think of it.

1:05

So something that might indicate

1:06

that there's something abnormal with the development

1:08

of the spinal cord canal contents

1:12

or, uh, the posterior elements or overlying soft tissues.

1:15

So that's gonna be any case of suspected tethered cord

1:18

or cord compression.

1:20

Suspected split cord malformation

1:22

or coddle regression syndrome on exam.

1:24

And then there's lots of syndromes that are associated

1:27

with spinal abnormalities.

1:28

And so we will, uh,

1:29

do screening ultrasound on those infants as well.

1:32

The most common is anorectal malformation

1:34

in our patient population.

1:37

In a patient who is postoperative

1:38

after a tethered cord release, if they're concerned

1:41

for cord re tethering, they might come to ultrasound.

1:44

And then last but not least, in an infant who, uh, presented

1:47

with concern for meningitis who is post lumbar puncture

1:50

to work up an infant with fever

1:53

or, uh, hypothermia, we might image with ultrasound to look

1:57

for post LP complications most commonly hemorrhage

2:01

or to see if there's enough CSF surrounding the lumbar spine

2:05

inferiorly for them to retet lumbar puncture to get CSF

2:09

to send off for lab analysis and culture.

2:13

So cutaneous stigmata that raised concern

2:15

for tethered cord are sacral dimples.

2:18

And when I say sacral dimple, I'm talking about the dimples

2:22

that are further away from the anus who have a deep, um,

2:25

non visualized pit screening is actually not recommended

2:29

for simple sacral dimples.

2:31

So a simple sacral dimple is a shallow dimple that is closer

2:34

to the infant's anus in our patient population.

2:37

We have a hard time convincing not only our pediatricians

2:40

but our neurosurgeons not to screen them.

2:42

Despite that there's evidence to suggest the vast majority

2:45

of those patients have normal ultrasounds.

2:48

So we still screen basically every sacral dimple

2:52

that comes our way, or anybody

2:53

who has some other cutaneous stigmata

2:56

to suggest spinal dism such as, uh,

2:59

hemi overlaying the corridor tuft

3:01

of hair overlaying the sacrum rather.

3:04

And here's a list of just some of the other cutaneous stigma

3:07

that might indicate, uh, spinal dys defect.

3:10

An occult spinal dysraphism such as a germal sinus,

3:13

a hairy patch, a rudimentary tail, um,

3:16

they might see a meningocele on, uh, on exam,

3:19

a hyperpigmented macular cafe lay macular

3:23

or a deviated natal cleft.

3:25

Potential contraindications.

3:26

And I say potential contraindications

3:28

because your neurosurgeon might still have specific

3:31

questions they want answered prior to operative management.

3:34

Um, and that is if you have an open spinal dystrophic defect

3:38

where cerebral spinal fluid is leaking, there's potential

3:41

for introducing infection if you are imaging

3:44

sonographic over an open, uh, spinal dystrophic defect.

3:48

So that's a potential contraindication.

3:50

Um, if you have concern that the skin is too thin

3:53

or non-intact overlying a closed neural tube defect,

3:58

or if you can't see, so if you have a one-year-old,

4:01

don't send that patient to a spinal ultrasound

4:03

because we're not gonna be able to see through

4:06

posterior elements that are fused.

4:07

So this is just a CT example.

4:10

Most of us are more familiar with looking at the, uh,

4:13

posterior arch at ct.

4:15

So this is a five-year-old infant and you can see how

4:18

and why we are able to image the, uh,

4:20

spinal canal contents at ultrasound prior to fusion.

4:24

And over the course of several weeks, uh, of age,

4:27

that gets smaller and smaller.

4:28

And so we can see less and less with ultrasound

4:31

because that the poster elements block our ultrasound

4:33

transducer unfortunately.

4:35

So if you look at the practice parameters, uh,

4:38

for indications for neonatal spine imaging,

4:41

it says you can attempt to image up to six months of age.

4:44

But in our practice,

4:45

we really have a hard time seeing anybody over the age

4:48

of four months of age

4:50

'cause the posterior elements get in the way.

4:52

We can still attempt it if the clinical team

4:55

has specific concerns.

4:56

And I've just flipped this, so you know

4:58

that we go from the posterior skin, um,

5:01

imaging from posterior

5:02

to anterior when we image these infants.

5:05

So these infants, we wanna make them again,

5:07

fad happy, ready for nappy.

5:09

We wanna make them warm and comfortable so they're not, um,

5:11

screaming and crying during this examination.

5:14

Most infants don't love tummy time, so it could be helpful

5:17

to have the patient's mother or father

5:19

or caregiver hold onto the infant

5:22

and image the patient while they're in

5:23

their caregiver's arms.

5:25

Um, if the spine is too straight,

5:27

we might have a hard time telling anatomic landmarks.

5:30

So sometimes it's helpful to place a rural towel under the

5:33

infant's hip to accentuate

5:34

that lumbosacral junction a little bit.

5:36

I'll show you some examples of why that's important.

5:39

We exclusively use a linear high frequency transducer image

5:42

in both the transverse

5:43

and longitudinal planes, um,

5:45

while we're looking at cord contents.

5:48

And then the money is gonna be cinematic images

5:50

where we're looking for normal movement

5:52

of the spinal cord and nerve root.

5:57

The um, other important image that you're gonna get

6:00

to be able to tell landmarks is the panoramic view

6:03

where the, you take your transducer

6:05

and you go along the entirety of the length

6:07

of the lumbosacral junction to be able to tell

6:10

what level you're looking at.

6:13

Um, if you have some difficulty visualizing

6:15

or if you have a patient who had a prior lumbar puncture

6:18

and doesn't have a ton of cerebral spinal fluid to be able

6:21

to see, well, you might consider imaging the patient upright

6:24

to kind of get that CSF to to fall dependently to be able

6:27

to see the cord and the nerve rootlets.

6:30

And then last but not least, you might consider imaging from

6:32

an anterior approach if there's concern for presacral mass,

6:36

either while you're imaging as you go through the sacrum

6:39

and Cox region or, um, just based on prenatal, uh, imaging

6:43

or on exam if there's concern for a presacral mass.

6:47

So, um, just some examples of that.

6:49

One of my texts always thinks that it's easier

6:51

to go when you're doing your panoramic view

6:54

to go from coddle to cephalon

6:56

because you, the baby does this like shimmy shake when you

6:59

go from superior to inferior.

7:00

So you might get a little bit, uh, more lucky going inferior

7:04

to superior rather than superior to inferior

7:06

for your panoramic view.

7:08

Just, uh, another example as you're going from, um, superior

7:11

to inferior, you can see that shimmy shake

7:13

that this baby does as we go superior to inferior.

7:16

So we have a little bit more success when we go inferior

7:19

to superior to get our panoramic view, to be able

7:22

to see the entirety of the thoracic

7:24

and lumbar vertebral bodies to be able to count levels.