PMC7068195_01
A-E: The accessory lower limb was arising from the lower back at the level of L2 to S1. It was pointing cranially. Grossly, it resembled a normal lower limb with a partially developed foot containing only big toe and the next adjacent toe. The accessory limb was bearing four blind ending gut loops of red color. These used to wet the clothing with their watery secretion. Additionally, there were areas with pitting and dimples, mimicking the natal cleft and anus
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F1
Clinical examination of the infant revealed a well-developed accessory lower limb arising from the back at the level of L2 through S1 vertebrae (Figure 1A-D).  On the accessory lower limb, there were four blind ending gut loops of red color (Figure 1E).
A: Plain X-rays showed the osseous components of the accessory lower limb. The arrow is pointing towards the rudimentary hemi-pelvis. B: Lumbosacral computed tomography with three dimensional reconstruction revealed deficient posterior bony elements at the level of L2 through SI vertebrae along with evidence of lipomyelomeningocele. It also confirmed an accessory lower limb attached to the right gluteal muscles. The limb had a rudimentary iliac bone (the arrow is pointing towards it), femur, tibia, fibula, rudimentary foot bones, hip and knee joints. C: MRI lumbosacral spine, sagittal view. D: MRI lumbosacral spine, axial view. The whole spine Magnetic resonance imaging (MRI) confirmed the presence of spinal dysraphism involving lumbar spine with deficient posterior elements. The spinal cord and thecal sac were protruding posteriorly and towards the left superiorly through the defect in the posterior elements at the level opposite L3 through S1 vertebrae, revealing a large lipomyelomeningocele measuring approximately 4.7x3x4.8 cm. The CT scan findings of the accessory lower limb were re-confirmed
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F2
Plain X-rays showed the osseous components of the accessory lower limb (Figure 2A). The limb had a rudimentary iliac bone, femur, tibia, fibula, rudimentary foot bones, hip and knee joints (Figure 2B). Whole spine magnetic resonance imaging (MRI) confirmed the presence of spinal dysraphism involving lumbar spine with deficient posterior elements (Figure 2C and D).
A: The infant was positioned prone on the operating room table for undertaking surgery. B: An elliptical skin incision with transverse orientation was designed to ensure adequate closure of the resultant defect after limb extirpation. C: The neural placord was carefully dissected, de-tethered from attachments and returned. Dural closure was performed. The overlying dorsolumbar fascia was closed. D: The skin was closed with subcuticular absorbable sutures. Steristrips were applied to support the wound. E: The wound was perfectly fine on the first dressing change on 5th postoperative day, after removal of steristrips. F: The ablated accessory limb
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F3
At the time of surgery, the patient was positioned prone on table (Figure 3A). An elliptical skin incision (transversely oriented on the lower back) was designed to ensure adequate closure of the resultant defect after limb extirpation (Figure 3B). The skin flaps were approximated in a tension free manner (Figure 3C). The wound was closed with subcutaneous absorbable sutures and steristrips were employed (Figure 3D). The immediate postoperative period was uneventful and the infant was discharged home on 5th postoperative day (Figure 3E). Figure 3F shows the ablated accessory limb.