Supplementary Material for: Spinal Dysraphism Presenting as Neuropathic Ulcers: A Case Report of a Delayed Diagnosis

Spinal dysraphism (SD) refers to the abnormal fusion of dorsal midline structures during embryogenesis. It encompasses a variety of congenital spinal defects, ranging from an overt defect in which neural tissue is exposed with no overlying skin (open SD) such as myelomeningoceles to skin-covered malformations (closed or "occult" SD). A 13-year-old boy presented with recurrent multiple painless ulcers and erosions over the tips of the toes, mainly involving the right foot with hemorrhagic crusts for five years. A review of systems revealed: back pain, urine incontinence, and numbness in his right knee. He was diagnosed with peripheral neuropathic ulcers and tethered cord syndrome secondary to spinal dysraphism and confirmed by MRI. He underwent cord detethering and lipoma resection as well as expectant therapy with satisfying outcomes. Physicians should consider early diagnosis of SD to avoid later neurological complication of SD (traction and/or pressure on the spinal cord), when infants are presented with such anomalies: MRI, close follow-up, and neurosurgical intervention may be recommended