3. 1. Introduction
• Adults with spina bifida and congenital anomalies of the spine are a patient
population that presents unique clinical challenges
• Approximately 85% of children born with spina bifida now live well into
adulthood and it is estimated that there are currently more adults living with
myelomeningocele than children
• Here we present the management of an enlarging, symptomatic lumbosacral
meningocele in a 45-year-old woman with history of lumbosacral lipo-
myelomeningocele
4. 2. Case Description
• This 45-year-old woman with past medical history of lumbosacral lipo-
myelomeningocele anatomically involving L2 through S5 vertebral levels,
functional L4 level, and previously treated with one prior surgery as a 3-year-old
• She had neurogenic bowel and bladder and previously received a diverting
colostomy and urostomy
• Importantly, she never required treatment for hydrocephalus such as ventriculo-
peritoneal shunting or prior imaging suggestive of such a diagnosis
• She was referred for neurosurgical evaluation of progressively enlarging back and
right flank mass
5. 2. Case Description
• She noted that she used to have a small “lump” on her
back near her lumbosacral surgical scar that had remained
relatively stable in size since her surgery as a child
• However, over the past several months she noted a
progressive enlargement of this “lump” such that it now
involved the lower back and had extended laterally to
involve the right flank (Figure 1A).
• Initially the mass was bothersome but not painful, with
increasing size the mass had begun to cause pain and
discomfort when sitting or laying down
Pre-operative lumbar meningocele:
(A) left lateral decubitus photograph
6. 2. Case Description
• Follow up cranial imaging was without evidence of
hydrocephalus and detailed ophthalmological evaluation
was without evidence of papilledema
• MR and CT imaging of the lumbar spine revealed a low
density, fluid-filled mass measuring approximately 13 x 8
cm and continuous with the lumbar thecal sac at L4
• MR imaging also revealed herniation of nerve roots into
only the proximal portion of the fluid filled mass
consistent with a meningocele (Figure. 1B)
• Treatment options were discussed and surgical treatment
involving resection and complex closure of the
meningocele
Pre-operative lumbar meningocele:
(B) Axial T2- weighted MRI
7. Intra Operative
• The meningocele was readily palpable and extreme care
was taken to prevent rupture of the sac (Figure. 2A)
• We identified the edges of the meningocele defect. A drill
was used to perform partial laminectomies at L3 and L4 in
an attempt to identify normal dura
• We then identified the stalk of the massive meningocele
and used blunt dissection to perform a circumferential
dissection around the stalk with care not to avulse it from
the thecal sac (Figure. 2B)
• We then continued the soft tissue dissection over the
very large meningocele and resected part of the fibrous
and fatty capsule over it
Figure 2. Intraoperative lumbar meningocele: (A), Initial exposure, (B) Isolation of origin
8. Intra Operative
• A massive amount of spinal fluid came out and the
meningocele decompressed itself
• There appeared to be no obvious spinal cord or other
neural tissue within the bulk of the meningocele or distal
stalk
• However, there appeared to be redundant nerve root that
had herniated into the proximal stalk and based on direct
stimulation innervated the left vastus lateralis muscle.
Microdissectors were used to reduce this nerve root
fascicle into the thecal sac
• Using bipolar cautery and sharp dissection with
Metzenbaum scissors, the meningocele was completely
resected along with part of its capsule (Figure. 2C)
Figure 2. Intraoperative lumbar
meningocele: (C) Excised sac
packed with gauze to recreate
approximate dimensions
9. Post Operative
• She immediately began the rehabilitation process by working with physical and
occupational therapy on post-operative day 1 and quickly transitioned from IV
analgesics to oral medications by post-operative day 2
• Patient was transferred to inpatient rehab on post-operative day 3 and continued
inpatient rehab for a total of 19 days
• At the time of discharge from inpatient rehab patient had resumed ambulation
with bracing and a rolling walker and did not have any recurrent positional
headaches
10. Control OPD
• At 4 month post-operative follow up,
patient was without evidence of
recurrence of mass, no clinical signs of
hydrocephalus, neurological
examination was at her pre-operative
baseline, and she had returned to her
pre operative mobility utilizing lower-
extremity braces and a single-point
cane
• At 1 year she remains without clinical
or radiographic evidence of recurrence
of meningocele (Figure. 3)
Figure 3. Post-operative lumbar meningocele:
(A) upright, lateral, standing photograph
(B) Axial T2-weighted MRI
11. 3. Discussion
• Efficient health care utilization for adult spina bifida patients is a rising concern in
our health care system, with analysis of nationwide inpatient sample database
revealing steady increases in hospital admissions and healthcare costs over the
past decade
• In the months preceding the expansion, patient was diagnosed with colon cancer
involving her ostomy site that required an extensive course of treatment with
several extended inpatient stays
• During these inpatient stays our patient spent significant amount of time
confined to a hospital bed and had significantly less activity. A plausible
consequence of this inactivity is weakening of the abdominal trunk musculature
allowing for a pre-existing residual meningocele to expand
12. 3. Discussion
Alternatively, a previously undiagnosed hydrocephalus was also strongly considered
as an etiology but is felt to be unlikely given ;
1) The patient’s presenting symptoms suggestive of low intracranial pressure
phenomena,
2) lack of corroborating pre-operative physical exam or radiographic findings,
3) A post-operative course without any complications of hydrocephalus after
obliteration of the meningocele e.g CSF leak, radiographic ventricular
enlargement or symptomatic hydrocephalus
The variety of expertise available aided in each step in our patient’s care including
initial diagnostic evaluation, pre-operative planning, intraoperative management,
and finally in post-operative care
13. 4. Conclusion
An expanding cohort of spina bifida patients live well into adult life and pose
unique challenges to physicians. Given the complex and delicate nature of their
pathology, surgical intervention for spina bifida patients should be done with a
team and may require adult and pediatric neurosurgeons, plastic surgeons, general
surgeons and urologists for optimum outcomes.
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