4-fetal spine Dr Ahmed Esawy

Dr. Ahmed Esawy
MBBS M.Sc
MD
Dr/AHMED ESAWY

Diagrammatic representation of ossification
centres found in each vertebra
Dr/AHMED ESAWY

spine
• Should looked in sagittal and axial plane and if possible in coronal.
• In the axial plane the three ossific centre should be identified with
their skin covering and should be seen wider in cervical region and
narrow at the sacrum .
• In sagittal plane the normal curvature of the spine can be seen with
the upward sweep of the sacrum ,the skin covering should be
identified and the alignment of the laminae and vertebral bodies
should also identified.
• In the coronal plane the alignment of the transverse processes and
laminae give railway track appearance of the spine which widens at
the head and narrowers at the sacrum .in this view the alignment of
the ribs can be seen also, and the spinal cord and couda equina may
be seen.
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Sonography of fetal spine using 3-D/ 4-D ultrasound reveals greater detail of the fetal spine in 3-
Dimensions. Ultrasound visualizes the ossified part of the fetal spine. The 3 main ossification
centers in the fetal vertebrae are: a) the centrum b) the right neural process and c) the left neural
process. The centrum forms the central part of the vertebral body. The postero-lateral parts of
the vertebrae are formed by the right and left neural processes.

Coronal views of the fetal spine. These images were obtained with three-dimensional
ultrasound from the same sonographic volume using different angulations and beam-
thicknesses. (a) A thin ultrasound beam is oriented through the bodies of the
vertebrae; (b) the same ultrasound beam is oriented more posteriorly to demonstrate
the posterior arches of the vertebrae; (c) a thick ultrasound beam is used to
demonstrate simultaneously the three ossification centers.
Dr/AHMED ESAWY

Coronal section of the fetal spine
demonstrating the three echoes representing
the ossification centers of each vertebra. The
iliac crests (IC) can be seen on either side of
the sacrum. Owing to the curvature of the
normal spine note that the whole spine is not
visualized in one image
Dr/AHMED ESAWY

• Longitudinal section of the fetal spine
demonstrating the upsweep of the sacrum
and the skin covering.
Dr/AHMED ESAWY

• Transverse section of the fetal abdomen
demonstrating the ‘U’ shape of a normal vertebra
Dr/AHMED ESAWY

Sagittal view of the fetal spine at midgestation. Using the unossified
spinous process of the vertebrae as an acoustic window,the contents of
the neural canal are demonstrated. The conus medullaris is normally
positioned at the level of the second lumbar vertebra (L2).
Dr/AHMED ESAWY

Transverse plane at 20 weeks. Note the subcutaneous tissue and intact skin line posterior to the
vertebra at each level and the convergent orientation of the vertebral arch ossification centres. A.
Sacral spine. Note the flattened triangular shape of the vertebra. B. Lumbar spine. Note the
triangular shape of the vertebra. C. Cervical spine. Note the squarish shape of the vertebra. D.
Thoracic spine. Note the triangular shape of the vertebra.
Dr/AHMED ESAWY

Appearance of normal fetal spine with 3D rendered transabdominal ultrasound at different
gestations. A. 15 weeks – right and left vertebral arch ossification centres approach each other at
the thoracic level but are still separate at the lumbosacral level. Note the absence of lumbosacral
ossification at this gestation. B. 20 weeks – the three ossification centres in the lumbosacral
region are readily apparent. C. 23 weeks & D. 25 weeks – vertebral arch ossification is complete.
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Sagittal plane at 20 weeks. A. Note the
convergence of the ossification centres of the
vertebral arch and body at the sacrum. B.& C. By
angling the probe to image through the unossified
spinous processes, the tip of the conus medullaris
(arrow) can be visualised

Dr/AHMED ESAWY
Coronal plane at 20 weeks. A. Note the distal
convergence of the vertebral arch ossification
centres. B. Note three ossification centres in the
lumbosacral spine

Dr/AHMED ESAWY
3D rendered images of the spine at 20 weeks. A. Note the appearances
of the vertebrae and the rib cage. B. By rotating the image, enhanced
visualisation of the ribs is possible

Dr/AHMED ESAWY
The use of multiplanar imaging to identify the level of the conus medullaris. A. Sagittal
view. The dot is orientated at the tip of the conusmedullaris. B. Transverse view. When
this is the reference image, a transverse line bisects the 3D rendered image (C) at the
level of the dot. C. 3D rendered image. Visualisation of the spine and ribs allows for
accurate counting of the vertebrae. In this case, the tip of the conus medullaris is at the
level of the green line – L2.

Prenatal
classification of
spine
abnormalities
Dr/AHMED ESAWY

• 1-Open neural tube defects
• 2-Closed neural tube defects
• 3-Vertebral abnormalities ( hemivertebrae,
block vertebrae, cleft or butterfly vertebrae,
sacral agenesis, and a lipomeningocele . most
sensitive features are flaring of the vertebral arch
ossification centres, abnormal spine curvature,
and short spine length. )
• 4-Multiple abnormalities (renal agenesis,sacral
agenesis and arthrogryposis of upper and lower
limbs and scoliosis )
Dr/AHMED ESAWY

NTDs :
• Two types of NTDs:
1- Open NTDs ( most common) :
- occur when the brain and/or spinal cord are
exposed at birth through a defect in the skull
or vertebrae.
• Spina bifida
• Anencephaly
• Encephalocele
Dr/AHMED ESAWY

2- closed NTDs (Rarer type ):
- occur when the spinal defect is covered by skin.
• lipomyelomeningocel
• lipomeningocele
• tethered spinal cord.
Dr/AHMED ESAWY

Neural Tube Defects
• What are the common Neural Tube Defects
(NTDs) ?
• Spina Bifida - 60%
• Anencephaly - 30%
• Encephalocele - 10%
Dr/AHMED ESAWY

What is Spina Bifida?
- A midline defect of the :
• bone,
• skin,
• spinal column, &/or
• spinal cord.
Dr/AHMED ESAWY

Summary of features of closed NTD
Dr/AHMED ESAWY

• The most common serious anomalies is open neural tube defect
which may be detected by loss of alignment of vertebral bodies and
absence of skin covering ,but in sever cases by identification of gross
kyphoscoliosis.
• The diagnosis can be difficult if the fetus is in breech and low sacral
lesion are readily overlooked ,identification of cranial signs associated
spina bifida e.g. the skull has lemon shape and cerebellum is banana
shape (these signs are also seen in 1% of normal fetuses) ,also
compare maternal serum Alfa fetoprotein.
Dr/AHMED ESAWY

Spina Bifida
• Spectrum Abnormalities
• Failure of NT to close
• Range:
– Spina Bfida Occulta
• Non-fusion of vertebral
arches
• Skin Intact
– Myelomeningocele
• Protruding Sac
• CSF, SC and nn roots
– Myeloschisis
• Totally Open Defect
Dr/AHMED ESAWY

Spina Bifida
• Spina Bifida is divided into two subclasses :
1 - Spina Bifida Occulta(closed ) :
- mildest form ( meninges do not herniate
through the opening in the spinal canal )
2 -Spina Bifida Cystic ( open) :
- meningocele and myelomeningocele .
Dr/AHMED ESAWY

Spina Bifida
• Failure of closure of the neural tube (3-4w) resulting in
exposed neural plate.
• Imbalance between the production and reabsoption rate of CSF in
the embryonic period
• Ventral defect
• Dorsal defect: spina bifida occulta, spina bifida aperta
• Longit. Scan (distorted the normal tram- line
appearance).
• Transverse scan (wide “U’’ shaped deformity instead of
discrete circles).
• Sonar + amniotic fluid AFP assay.
• Associated anomalies (hydrocephalus-encephalocele).
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Vertebral features of open NTD – A. Flared vertebral arch
ossification centres in transverse. Note the disruption to
the subcutaneous tissue and skin line posterior to the
vertebra. B. Widened vertebral arches in coronal. C.
Disruption of the skin line posterior to the vertebral defect
with bulging meninges

Dr/AHMED ESAWY
3D rendered image of open NTD. A. widened lumbosacral spine indicative of a
defect involving L2 to S5. B. Normal spine for comparison.

Spina Bifida
• Primary failure of closeure of the neuropore
Dr/AHMED ESAWY

Spina Bifida
• Most Common: Lumbosacral
• Can occur anywhere in spine
• US Findings:
– Outward Splaying of Laminae
– Soft Tissue Defect
• overlies bony defect
– Protruding Sac (+/- neural tissue)
– +/- Chiari II Malformation
– +/- Ventriculomegaly (75%)
– Banana Sign
• Cerebellar hemispheres squashed
into shape banana
• Cisterna Magna is small or gone
– Lemon Sign
• Bossing of frontal bones
• Lemon shaped head on axial scan
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Longitudinal
sonogram of a fetal
spine
demonstrates a
spinal defect
(arrow) covered
by membrane

Lemon Sign Banana Sign
Meningomyelocele Sac
Meningomyelocele Sac on Newborn
Spina bifida
Dr/AHMED ESAWY

Spina Bifida
• There are many forms of neural tube defects,
Spina Bifida is the most common of the
central nervous system
• A midline defect of the vertebrae that results
in exposure of the contents of the neural canal
Can be genetic
Dr/AHMED ESAWY

 Meningocele
◦ Anechoic cystic mass
◦ Rarely covered by skin
◦ Does not contain neural tissue
 Myelomeningocele
◦ Complex cystic mass
◦ Contains neural tissue
 Chiari II Malformation seen in 99% of cases
◦ Absent cisterna magna
 “Banana Sign” Abnormal cerebellum
 Ventriculomegaly
 Lemon shaped calvarium
Ultrasound Findings
Dr/AHMED ESAWY

Myelomeningocele
• The spinal cord and nerve roots herniate into
a sac comprising the meninges.
• This sac protrudes through the bone and
musculocutaneous defect.
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Lipomengocele – A. Sagittal view demonstrates a mostly echogenic
subcutaneous mass with a central anechoic area (arrow). Note the absence of
vertebral arch ossification centres. B. Coronal view demonstrating a widening of
the lower spine and an absence of the vertebral arch ossification centres. C.
Transverse view demonstrating a single ossification centre.

Dr/AHMED ESAWY
Lipomeningocele – A. Sagittal view
demonstrating absent lower sacral
elements (arrow) B. Post mortem radiology
confirming partial sacral agenesis

Abnormal spine
Myelomeningocele. Sagittal demonstrates the break in
the skin line.Transaxial shows the myelomeningocele
sac and divergent posterior ossification centers .coronal
shows widening of the lamina.
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Longitudinal scan shows the typical
features of meningocele

Myelomeningocele
Myelomeningocele
Dr/AHMED ESAWY

Myelocele
Myelocele
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Dr/AHMED ESAWY
Cranial features of the Chiari II malformation . A. Frontal bossing or ‘lemon’
shaped head. B. Cerebellar distortion or ‘banana’ shaped cerebellum and
obliterated cisterna magna. C. Marked ventriculomegaly.

Vertebral abnormalities
Dr/AHMED ESAWY

Dr/AHMED ESAWY
schematic representation of
formation defects
schematic representation of
segmentation defects

Syndromes associated with
vertebral defects
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Abnormal spine curvature.
A .abnormal spine curvature demonstrated
at an early gestation (12 weeks) (arrow)
B. abnormal curvature at 21 weeks (arrow)
C. abnormal curvature at 20 weeks
detected despite oligohydramnios (arrow).

Dr/AHMED ESAWY
Cleft thoracic vertebrae – 3D coronal image acquired at 21 weeks gestation
demonstrating cleft thoracic vertebrae (brace). Note the rib asymmetry (7 ribs on the
right, 9 ribs on the left). B. Corresponding post mortem radiograph demonstrating
thoracic butterfly vertebrae (brace) C. Rotating the 3D coronal dataset demonstrates rib
fusion.

Dr/AHMED ESAWY
Block vertebrae – A. L4/5 block vertebrae revealed by rotating the 3D dataset
acquired at 21 weeks gestation (arrow). B. Corresponding post natal radiograph.

Dr/AHMED ESAWY
Hemivertebra – A. 3D coronal image demonstrating T6 hemivertebra at 19 weeks
gestation (arrow).B. Corresponding post natal radiograph

MIXED,COMPLEX
ABNORMALITIES
Dr/AHMED ESAWY

Dr/AHMED ESAWY
Sacral agenesis – A. Coronal view
at 15 weeks demonstrating an
abrupt termination of the distal spine
and lack of tapering of ossification
centres toward each other. Note the
lower limb arthrogryposis. B.
Coronal view of a normal fetal spine
at 15 weeks. Although sacral
ossification is incomplete at this
gestation, note the tapering of the
distal spine.

Dr/AHMED ESAWY
Sacral agenesis – Sagittal view
at 21 weeks demonstrating a
shortened spine B. Sagittal view
of a normal fetal spine at 21
weeks.

Sacrococcygeal teratoma
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One month later
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fetal caudal regression syndrome
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sacrococcygeal teratoma
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Caudal Regression
Syndrome
in the Fetus
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Differences between CRS and
Sirenomelia
Dr/AHMED ESAWY

Transabdominal US images of the head of the fetus
at 22 weeks gestation. (a) The ventricles (V) and (b)
the cerebellum (C) and cisterna magna (arrow) are of
normal size and appearance. There is no Arnold-
Chiari malformation.

Transabdominal US image of the spine of the
fetus at 22 weeks gestation. The ossified spine
ends in the midlumbar region (arrow).

Transabdominal US image of the legs of the fetus at 22
weeks gestation. The orientation of the legs did not change
during the examination. Soft tissue of the lower extremities is
markedly decreased (arrows), which is consistent with severe
atrophy. The right foot (f) is abnormally hyperextended and
rotated, although it is not a classic club foot.

Sagittal half-Fourier single-shot RARE MR image (single-shot;
effective echo time, 64 msec; field of view, 27 × 31 cm;
matrix, 168 × 256; echo train length, 72; section thickness, 4
mm; one signal acquired) of a 22-week fetus. The lower
portion of the body is small compared with the midbody and
chest. The lower extremities (arrows) appear abnormally
extended and atrophied. Structures above the level of L3 and
intracranial anatomy appear normal.

Transverse half-Fourier single-shot RARE MR image (single-
shot; effective echo time, 64 msec; field of view, 31 × 31 cm;
mm; one signal acquired) of a 22-week fetus. Two kidneys
with a normal appearance (arrows) are present. Note the
ossified spine (S) at the level of the midkidneys and the
atrophic lower extremities (L).

Transverse half-Fourier single-shot RARE MR image (single-
shot; effective echo time, 64 msec; field of view, 31 × 31 cm;
mm; one signal acquired) of a 22-week fetus. A scrotum (S)
and a small phallus (arrow) are present. No testicles are seen
within the scrotum. The phallus is too small to be considered
normal male genitalia.

Frontal radiograph of chest and abdomen of newborn infant
with CRS. There are vertebral segmental anomalies from T6
through T9. Vertebral body L3 is dysplastic, and L4 and L5 are
absent. The sacrum is absent. The left 5th and 6th ribs
(arrows) are dysplastic.

Case of CRS
Transvaginal sonogram
showing absence of the
lower spine.in first
trimester Dr/AHMED ESAWY
Transvaginal sonogram showing
lower limb abnormalities.

• Lateral radiograph
of the fetus. Note
the absence of the
lumbar spine and
sacrum.
Dr/AHMED ESAWY

Dr/AHMED ESAWY
CASE TYPE II
22 weeks; the image 1 shows caudal part of the fetal spine. The sacral
part of the spine is missing. The image 2 shows the lower extremities
of the fetus with hypoplastic musculature

Dr/AHMED ESAWY
22 weeks; the image 3 represents a 3D scan of the lower fetal
spine. The sacrum is missing and the iliac wings are
positioned in midline close to each other. The image B shows
transverse scan of the normally looking fetal head.

Dr/AHMED ESAWY
CASE TYPE III
16 weeks; the image A shows transverse scan of the fetal head. Note the
lemon shape of the fetal skull, abnormal shape of the fetal vermis ("banana
sign") caused by the lumbar myelomeningocele, the sac of which is visible on
the image B.

Dr/AHMED ESAWY
The images show X-ray(image a) and 3D (image b) representations of the fetal
pelvis and legs. The legs are kept in fixed flexed position and the sacrum and
lumbar vertebrae are missing

Dr/AHMED ESAWY
CASE type IV
21 weeks; the images shows sagittal scan of the fetal spine. Note that the
caudal part of the spine distally to the thoracic vertebrae is missing.

Dr/AHMED ESAWY
The image a shows a transverse scan of the fetal abdomen. Note that the spine
at this level is missing. The image b shows flexed lower extremity of the fetus.
The arrow points at the popliteal pterygium.

Dr/AHMED ESAWY
Coronal plane of the fetal spine showing kyphosis and distortion of the
thoracolumbar spine.

Dr/AHMED ESAWY
Coronal plane of the D12 vertebra showing
the wedge appearance

Dr/AHMED ESAWY
Longitudinal ultrasonographic scans of the spine of a second trimester
fetus with hemivertebra

Dr/AHMED ESAWY
Longitudinal ultrasonographic scan of the spine of a second
trimester fetus with hemivertebra

Dr/AHMED ESAWY
Fetus with spondylocostal dysplasia. Demonstrative sagittal view of the thoracic spine
acquired during second-trimester ultrasound shows abnormal curvature of
the spine. Posterior ribs do not appear fused. Segmentation-fusion anomalies were
appreciable in the lower thoracic spine (not shown).

Dr/AHMED ESAWY
Fetus with spondylocostal dysplasia. Coronal HASTE (A) and axial FISP (B) images
from a third-trimester fetal MRI study show a lower thoracic left-convex curve. The
left lung volume appeared subjectively smaller on the fetal MRI study. Neither T2-
weighted sequence elucidated rib anatomy.

Dr/AHMED ESAWY
Iniencephaly, 14 weeks, 6 days gestational age. A.
Coronal scan of the fetal spine
showing large defect of the cervico- thoracic
region of the spine (arrows). B. Transverse
oblique scans of the fetal head showing occipital
defect with a large meningomyelocele.
C.3D image showing fetal profile with
meningomyelocele and permanent retroflexion of
the head.

Fetal spinal anomalies in a first-
trimester
Dr/AHMED ESAWY

Transabdominal scan of a first-trimester fetus with body
stalk anomaly. (A) There are several anomalies including distortion
of the fetal spine, a thoracic myelomeningocele, and an anterior
abdominal wall defect. (B) Transverse view of the thorax shows the
thoracic myelomeningocele
Dr/AHMED ESAWY

Body stalk anomaly at 13 weeks. (A) There is an abnormal
curvature and shortening of the spine (Sp) associated with a
large omphalocele (O) attached to the placenta
Dr/AHMED ESAWY

First-trimester sonographic findings in a fetus with the Vertebral, Anal, Cardiac, Tracheal,
Esophageal, Renal, and Limb (VACTERL)
association. (A) There was increased nuchal translucency thickness, shortening of the fetal spine,
kyphoscoliosis, and a lumbosacral spina bifida.
(B) Surface-rendering three-dimensional sonographic imaging depicting the spinal abnormalities.
(C) X-ray of the infant depicting the severe spinal, thoracic, abdominal, and pelvic abnormalities
Dr/AHMED ESAWY

(A) Transabdominal scan in a first-trimester fetus with
localized thoracic kyphoscoliosis at 13 weeks. (B) At birth,
multiple costo-vertebral malformations were noted
Dr/AHMED ESAWY

(A) Transabdominal scan of a first-trimester fetus with spina bifida. There is severe
angulation of the lumbosacral spine.
(B) Longitudinal view at 13 weeks in a fetus with spina bifida undetected during the
first trimester. Note suboptimal visualization of the fetal spine. (C) Transverse view of
the fetal head. In retrospect,a subtle ‘lemon-shaped’ skull was noted
Dr/AHMED ESAWY

4-fetal spine Dr Ahmed Esawy

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