Lumbosacral meningomyelocele repaired in infancy. Back pain in lumbosacral region for 1 year with easy fatigability. Please evaluate tethered cord, lipoma. From EMR: Waardenburg syndrome. There is a linear area of low signal through the midline posterior elements of L5, suggesting spina bifida occulta at this level. Caudal to this level, there is open spinal dysraphism. Within the dorsal sacral region are presumed postsurgical changes from a prior myelomeningocele repair, with little subcutaneous tissue remaining overlying the dysraphic defect.The spinal cord is low lying and extends to at least the L5-S1 level, where it appears to splay over a large oval intradural structure. This finding is of high T2/STIR signal, perhaps slightly greater in signal than adjacent CSF. On T1-weighted images, this is also mildly hyperintense to CSF. There is slight heterogeneity noted within the contents of this structure, suggesting a possible complex cystic fluid component, possibly with internal septations and/or debris. Following contrast, there is thin discontinuous peripheral enhancement. The fluid collection measures 1.9 x 2.1 cm in greatest axial dimensions (series 701, image 34) at the approximate S1-S2 level, x 3.4 cm CC. The dorsal aspect of this structure is adherent to the dorsal ectatic thecal sac at this level. There is no fat signal to indicate associated lipomatous component. There is no evidence of associated abnormal signal within the visualized distal cord. On prone sequences, the distal spinal cord remains unchanged in position, without ventral motion, suggestive of tethering.The lumbar spine is without canal compromise or neuroforaminal narrowing. The remaining partially visualized retroperitoneal structures appear within normal limits.
1.Expected postoperative changes from a prior myelomeningocele repair with evidence of sacral spinal dysraphism with spina bifida occulta at L5.2.Low-lying spinal cord terminating at best at the L5-S1 level with imaging findings suggestive of tethering, for which clinical correlation is recommended. No syringohydromyelia identified in the visualized distal cord.3.Prominent circumscribed intradural oval structure which appears to arise from the distal splayed ends of the low-lying cord, with mild internal heterogeneity and minimal discontinuous peripheral enhancement. The differential includes primarily an epidermoid especially provided patient's history of previous surgical repair, arachnoid cyst or other complex cyst, less likely terminal myelocystocele, as the distal cord is otherwise unremarkable without evidence of syringohydromyelia, or neoplasm. Previous pre-surgery imaging would be helpful for comparison, if it can be obtained. Otherwise, the patient may benefit from additional MRI diffusion weighted sequences to exclude an epidermoid.