PMC7655999_01
Preoperative sagittal (a) and axial (b and c) T2 MRI of the cervical spine demonstrating intramedullary T2 signal changes and a small syrinx associated with a dorsally projecting exophytic cervical myelomeningocele terminating in the subcutaneous fat.
SNI-11-362-g001.jpg
PMC7655999_01_SNI-11-362-g001.jpg
F1
T2 hyperintensity at C4-C5. There was an associated defect of the bony posterior elements with projection of the neural elements into the dorsal subcutaneous soft tissue [Figure 1].
Preoperative sagittal (left) and axial (right) T2 MRI of the lumbar spine demonstrating a low-lying conus and associated diastematomyelia at L4.
SNI-11-362-g002.jpg
PMC7655999_01_SNI-11-362-g002.jpg
F2
This prompted an MRI of the lumbar spine which demonstrated underlying diastematomyelia with a low-lying conus [Figure 2].
Intraoperative views of the cervical myelomeningocele (cranial at right and caudal at left in each image). (a) Myelomeningocele sac (asterisk) extending through the fascia (f) and terminating in the subcutaneous adipose tissue (a). (b and c) Myelomeningocele emanating from the normal dura (d) and contiguous with it superiorly and inferiorly. (d) Dorsal projection of the neural elements (n) after dissection from the overlying myelomeningocele sac. (e) Pial closure of the dysplastic neural stump. (f) The free dysplastic neural stump at rest before dural closure.
SNI-11-362-g003.jpg
PMC7655999_01_SNI-11-362-g003.jpg
F3
The sac was then separated from the overlying soft tissue [Figure 3a]. The exposed native dura was contiguous with the myelomeningocele sac [Figure 3b and c]. The dorsal projection terminated in dysplastic spinal cord that fused with the overlying dural sac [Figure 3d]. The dorsal projection was sectioned at this location and the pial closed [Figure 3e]. Left alone, the stalk came to a resting position along the dorsal surface of the rostral spinal cord [Figure 3f].
Hematoxylin and eosin staining of the myelomeningocele at the region of the neural-meningeal attachment. Left: low magnification study revealed fibrosis and collagen fiber bundles with prominent interfiber clefts (arrowhead), likely filled with cerebrospinal fluid. Dura is seen at left (asterisk), leptomeninges at center, and bands of neuroglial tissue (arrow) at right. Right: inspection at high magnification showed the clefts (arrowhead) between collagen fibers at left and bundles of neuroglial tissue (arrow) and meninges (asterisk) at right. Neuropil containing scattered oligodendrocytes with a dark nuclei and slight perinuclear halo is readily identified within the neuroglial tissue.
SNI-11-362-g004.jpg
PMC7655999_01_SNI-11-362-g004.jpg
F4
The dysplastic portion of the dorsal projection along with its fused overlying dura was examined [Figure 4].
Postoperative sagittal (left) and axial (right) T2 MRI of the cervical spine showing successful detethering of the cervical myelomeningocele without neural compression at 4 months follow-up.
SNI-11-362-g005.jpg
PMC7655999_01_SNI-11-362-g005.jpg
F5
At 4 months follow-up, he had regained full strength in his left hand, and MRI showed a successful detethering without neural compression [Figure 5].