US of The Pediatric Spine: Technique, Anatomy, Normal Variants, and Pathologic Condition 2013

US of the Pediatric Spine: Technique, Anatomy, Normal
Variants, and Pathologic Condition
Award: Cum Laude

Poster No.: C-1001
Congress: ECR 2013
Type: Educational Exhibit
Authors: D. I. Cha, T. Y. Jeon, S.-Y. Yoo, J. H. Kim, H. Eo; Seoul/KR
Keywords: Ultrasound, Pediatric, Education, Education and training
DOI: 10.1594/ecr2013/C-1001
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Learning objectives
To become familiar with the Techniques of US of the Pediatric Spine and to know the
Anatomy, the Normal Variants, and Pathologic Conditions.
Background
Spine US is a useful screening method for occult spinal anomalies; it can demonstrate
normal anatomy and normal variants that may simulate disorders. Therefore, radiologists
should be familiar with pediatric US techniques and normal anatomies on US.
Imaging findings OR Procedure details
Indications
• Midline cutaneous malformations
-Dimple
-Hemangiomatous lesion
-Hairy lesion
-Skin defect
-Asymmetric gluteal crease
• Skin-covered mass
• Others
-Extremity and foot deformities
-Anorectal malformations
-Genitourinary malformations
Technique
Page 2 of 29
Fig. 1: Scanning technique
References: Department of Radiology and Center for Imaging, Sungkyunkwan
University School of Medicine, Samsung Medical Center - Seoul/KR
•Prone with small pillow or decubitus position
-To create a kyphosis
•High frequency (8-15 MHz) linear-array transducer
•Optimal in the first 3 months
-Midline scan over the spinous processes
•Limited window in infants older than 4 months by ossified spinous processes
-Paramedian scan
Longitudinal scan
Fig. 2: Normal anatomy-Longitudinal view
Page 3 of 29
Transverse scan
Fig. 3: Normal anatomy-Axial view

Normal anatomy
•Tip of the conus medullaris
-At birth : L 2-3
-3 month : L 1-2
-Counting method
•Ossification center of S5
•Caudal end of dural sac (S 1-2)
•Curvature of spine (L5)
•Renal hilum (L 1-2)
•Filum terminale thickness
-Normal : < 2 mm
-Best measured at L5-S1
Page 4 of 29
Fig. 4: Normal anatomy of the spinal canal and its contents in a 3-day-old newborn.
Sagittal US scan of the thoracolumbar spine.
Sagittal US scan of the craniocervical junction
Normal variant
1. Filar cyst
Page 5 of 29
• Midline location within filum, just below conus medullaris
• Well-defined, fusiform shaped cystic lesion
Fig. 6: Filar cyst

2. Transient dilatation of central canal
This seems to be an incidental finding in healthy newborns and disappears mostly during
the first weeks of postnatal life.
Page 6 of 29
Fig. 7: Transient dilatation of central canal
3. Ventriculus terminalis
•Cystic central dilatation of the distal cord
•Due to incomplete fetal regression of the embryonic terminal ventricle in the conus
medullaris.
Fig. 8: Ventriculus terminalis

References: Lowe L et al (2007). Sonography of the Neonatal Spine.
AJR;188:733-738
Development of spinal cord
•Primary neurulation
•Secondary neurulation
- Canalization and retrogressive differentiation
Page 7 of 29
Primary neurulation
Fig. 9: Primary neurulation

1. Focal unilateral premature disjunction
: Lipomyelomeningocele
Longitudinal scan shows a low tethered spinal cord (short arrows). There is distal
dysraphism with a subcutaneous lipoma (arrowheads) abutting the distal cord and
posterior extension of the meninges containing neural elements (long arrows).
Page 8 of 29
Fig. 10: Lipomyelomeningocele
2. Incomplete disjunction
: Dorsal dermal sinus
Dorsal dermal sinus with a hypoechoic tract (arrow) extending through the fat to the thecal
sac. The cord (arrowhead) is low-lying and tethered.
Fig. 11: Dorsal dermal sinus

Page 9 of 29
3. Focal non-disjunction
: Myelomeningocele
Chiari II malformation in one day old newborn: MR images show caudally displaced conus
and entering the neural placode dorsal to the sac (arrows) through the splayed posterior
elements of spine.
Post-op myelomeningocele in same patient: Longitudinal views show displacement of

conus caudally with attached to the surgical site (arrowheads).
Fig. 12: Myelomeningocele

Secondary neurulation
- Canalization and retrogressive differentiation
By the age of 30 days, caudal cell mass coalesce to form a tubular structure that unites
with the neural tube. At about 38 days, the cell mass and central lumen of the caudal
neural tube decrease in size through apoptosis. The segment formed by this process
eventually forms the conus medullaris, terminal ventricle and filum terminale.
Page 10 of 29
Fig. 13: Secondary neurulation - Canalization and retrogressive differentiation
- Failure of 2ndary neurulation
• Thickening of filum terminale
• Filar lipoma
• Sacrococcygeal teratoma
• Caudal spinal anomaly
• Caudal regression syndrome
1. Thickening of filum terminale

: Filar lipoma
Longitudinal and transverse sonograms show a thickened, echogenic distal filum

terminale and borderline low-lying conus at L2-3. MR image of the same patient shows
high signal fat within the filum terminale, representing a lipoma.
Page 11 of 29
Fig. 14: Filar lipoma
2. Tethered spinal cord

: Filar lipoma
Longitudinal scan through the distal spine shows a thickened, echogenic distal filum
terminale owing to a lipoma (arrows). The conus is elongated and tapered, suggesting
cord tethering (arrowheads).
Page 12 of 29
Fig. 15: Filar lipoma with Tethered spinal cord
3. Sacrococcygeal teratoma
Longitudinal scan in a neonate with perinatally diagnosed pelvic mass show a complex
cystic mass below the coccyx. This tumor dose not extend to the spinal canal.
Fig. 16: Sacrococcygeal teratoma
Page 13 of 29
4. Caudal spinal anomaly
- Sacral segmentation anomly
Fig. 17: Sacral segmentation anomaly

5. Caudal regression syndrome
Longitudinal scan of the distal spine shows abrupt termination of the spinal cord at L1
(arrows). The terminus of the cord has a blunted and squared shape, rather than a
normally tapered configuration.
Typical US features:
(a) A blunted or wedge shape conus that terminates above L1
Page 14 of 29
(b) An elongated conus that is tethered by a thickened filum terminale or
intraspinal lipoma and ends below L1
Fig. 18: Caudal regression syndrome

6. Unknown embryonic origin
Page 15 of 29
: Meningocele
Longitudinal scan shows posterior herniation of CSF-filled meninges through a posterior

bony vertebral defect, producing a subcutaneous cyst-like mass (arrows). On transverse
scan, there is a herniated nerve root (arrowheads) within the sac.
7. VATER syndrome with low-lying conus and filar lipoma
Plain radiograph shows multiple vertebral body segmentation defects (arrowheads).

Longitudinal scan of the spine shows a thickened and echogenic filum terminale,
representing a lipoma (arrows). This patient has horseshoe kidney (asterisk).
Fig. 20: VATER syndrome with low-lying conus and filar lipoma
8. Currarino syndrome (Lipomyelomeningocele with immature teratoma)
Longitudinal scan shows a low-lying conus medullaris (arrowheads) with hydromyelia.

And note that protruding heterogenous fatty mass (long arrows) through a ventral sacral
defect. Plain radiograph demonstrates typical scimitar sacrum (short arrows). The lesion
was proved to be pathologically lipomyelomeningocele with immature teratoma.
Page 16 of 29
Fig. 21: Currarino syndrome
Images for this section:
Fig. 1: Scanning technique
Page 17 of 29
Fig. 2: Normal anatomy-Longitudinal view
Fig. 3: Normal anatomy-Axial view
Page 18 of 29
Sagittal US scan of the thoracolumbar spine.
Sagittal US scan of the craniocervical junction
Fig. 11: Dorsal dermal sinus
Page 19 of 29
Fig. 10: Lipomyelomeningocele
Fig. 8: Ventriculus terminalis
Page 20 of 29
Fig. 7: Transient dilatation of central canal
Fig. 6: Filar cyst
Page 21 of 29
Fig. 12: Myelomeningocele
Fig. 9: Primary neurulation
Page 22 of 29
Fig. 19: Meningocele
Page 23 of 29
Fig. 18: Caudal regression syndrome
Page 24 of 29
Fig. 17: Sacral segmentation anomaly
Fig. 16: Sacrococcygeal teratoma
Page 25 of 29
Fig. 15: Filar lipoma with Tethered spinal cord
Fig. 14: Filar lipoma
Page 26 of 29
Fig. 13: Secondary neurulation - Canalization and retrogressive differentiation
Fig. 21: Currarino syndrome
Page 27 of 29
Fig. 20: VATER syndrome with low-lying conus and filar lipoma
Page 28 of 29
Conclusion
US should be considered the initial method for investigating the spinal cord, and MRI
may be the next imaging modality in those with an abnormal findings on spine US.
References
1. Lowe L et al. Sonography of the neonatal spine: part 1, Normal anatomy, imaging
pitfalls, and variations that may simulate disorders. AJR (2007);188:733-738
2. Lowe L et al. Sonography of the Neonatal Spine: Part 2, Spinal Disorders. AJR
(2007);188:739-744
3. Barkovich AJ. Normal development of the neonatal and infant brain, skull, and spine.
In: Barkovich, AJ. Pediatric neuroimaging, 4th ed. Philadelphia, PA: Lippincott Williams
& Wilkins, 2005:710, 723, 732, 735
4. Dick EA, Patel K, Owens CM, De Bruyn R. Spinal ultrasound in infants. Br J Radiol
2002; 75:384-392
5. Unsinn KM, Geley T, Freund MC, Gassner I. US of the spinal cord in newborns:
spectrum of normal findings, variants, congenital anomalies, and acquired diseases.
RadioGraphics 2000; 20:923-938
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US of the Pediatric Spine: Technique, Anatomy, Normal

Variants, and Pathologic Condition

Award: Cum Laude

Imaging findings OR Procedure details

• Midline cutaneous malformations

-Asymmetric gluteal crease

-Extremity and foot deformities

-To create a kyphosis

•High frequency (8-15 MHz) linear-array transducer

•Optimal in the first 3 months

-Midline scan over the spinous processes

•Limited window in infants older than 4 months by ossified spinous processes

Fig. 2: Normal anatomy-Longitudinal view

Fig. 3: Normal anatomy-Axial view

•Tip of the conus medullaris

-At birth : L 2-3

•Caudal end of dural sac (S 1-2)

•Curvature of spine (L5)

•Renal hilum (L 1-2)

•Filum terminale thickness

-Best measured at L5-S1

• Well-defined, fusiform shaped cystic lesion

Fig. 6: Filar cyst

2. Transient dilatation of central canal

•Cystic central dilatation of the distal cord

Fig. 8: Ventriculus terminalis

Development of spinal cord

- Canalization and retrogressive differentiation

Fig. 9: Primary neurulation

1. Focal unilateral premature disjunction

: Dorsal dermal sinus

Fig. 11: Dorsal dermal sinus

Post-op myelomeningocele in same patient: Longitudinal views show displacement of

Fig. 12: Myelomeningocele

- Canalization and retrogressive differentiation

- Failure of 2ndary neurulation

• Thickening of filum terminale

• Caudal spinal anomaly

• Caudal regression syndrome

1. Thickening of filum terminale

Longitudinal and transverse sonograms show a thickened, echogenic distal filum

2. Tethered spinal cord

Fig. 16: Sacrococcygeal teratoma

4. Caudal spinal anomaly

- Sacral segmentation anomly

Fig. 17: Sacral segmentation anomaly

5. Caudal regression syndrome

(a) A blunted or wedge shape conus that terminates above L1

intraspinal lipoma and ends below L1

Fig. 18: Caudal regression syndrome

6. Unknown embryonic origin

Longitudinal scan shows posterior herniation of CSF-filled meninges through a posterior

7. VATER syndrome with low-lying conus and filar lipoma

Plain radiograph shows multiple vertebral body segmentation defects (arrowheads).

8. Currarino syndrome (Lipomyelomeningocele with immature teratoma)

Longitudinal scan shows a low-lying conus medullaris (arrowheads) with hydromyelia.

Images for this section:

Fig. 1: Scanning technique

Fig. 3: Normal anatomy-Axial view

Fig. 11: Dorsal dermal sinus

Fig. 8: Ventriculus terminalis

Fig. 6: Filar cyst

Fig. 9: Primary neurulation