Spinal ultrasound in neonates and infants. Normal and pathologic findings. Correlation with MRI results

Neonatologie, Neurologie Pediatrică. Life Memorial Hospital, București, Universitatea ”Titu Maiorescu”, Bucureşti, Facultatea de MedicinăObiectiv: Cercetarea a avut drept obiective stabilirea fezabilităţii ecografiei spinale la nou-născut şi sugarul mic, identificarea imaginilor ecografice normale la diferite vârste, identificarea concordanţei între datele ecografice şi cele RMN în cazul disrafismelor spinale. Material şi metode: Pentru stabilirea fezabilităţii ecografiei spinale şi a identificării imaginilor normale au fost efectuate 350 de ecografii spinale la nou-născuţi normali, la termen. Au fost efectuate secţiuni longitudinale şi transversale la nivel cervical, toracic, lombar şi sacro-coccigian, folosind o sondă liniară cu frecvenţa de 10 Hz. Au fost notate: poziţia şi mobilitatea maduvei, diametrele măduvei şi ale canalului medular la nivel cervical, toracic, lombar, poziţia conus medullaris, diametrul filum terminale, prezenţa de chisturi de filum terminale sau conus medular. Pentru a se stabili vârsta până la care este fezabilă ecografia spinală, au fost trecute în revistă ecografiile spinale efectuate la pacienţii din cadrul programului de urmărire pentru nou-născuţii cu risc. Au fost de asemenea investigate cu aceeaşi tehnică, 40 de cazuri de nou-născuţi cu risc de disrafism spinal oculta, indicat prin prezenţa de stigmate cutanate, sinusuri lombo-sacrate, mase mediane sau paramediane, anomalii detectate intrauterin. Pacienţii au beneficiat de examen RMN pentru confirmarea leziunilor identificate ecografic. În anumite cazuri a fost efectuată urmărirea ecografică a pacienţilor cu coloană fixată (tethered cord) sau lipo-mielomeningocel pentru a ajuta la fixarea momentului operator. Rezultate: Nivelul conus medullaris a fost identificat a fi la nivelul vertebrei L1 în 88 de cazuri (25.1%), spaţiul L1-L2 în 203 cazuri (58%) şi sub nivelul L2 în 59 de cazuri (16.8%). Grosimea filum terminale a fost de 1.8 (+ 0.5 cm). Nu au fost identificate defecte spinale în cazul nou-născuţilor normali, fără stigmate. Au fost identificate un număr de 5 chisturi de filum terminale şi 3 cazuri de ventriculus terminalis, fără semnificaţie patologică. În cadrul programului de urmărire pentru nou-născuţii cu risc, au fost efectuate ecografii spinale la un număr de 36 de pacienţi. În 32 din cazuri, ecografiile au fost efectuate până la vârsta de 3 luni, structurile intravertebrale fiind vizibile la această vârstă. În 4 cazuri au fost efectuate ecografii şi la vârstele de 4 şi 6 luni; ecografiile de la 4 luni au decelat structurile cu suficientă acurateţe, imaginile fiind parţial vizibile la unul dintre pacienţi la vârsta de 6 luni, şi nevizibile la ceilalţi. În 4 cazuri, pacienţii au ajuns la ecografie după vârsta de 5 luni, în această situaţie structurile nu au mai putut fi vizualizate. Indicaţiile pentru ecografie spinală pentru risc de disrafism au fost reprezentate de sinusuri sacro-coccigiene – 24 cazuri, hemangioame în regiunea vertebrală sau paravertebrale – 6 cazuri, zone hiperpigmentate în regiunea vertebrală V cazuri şi mase tumorale lombosacrate – 2 cazuri. Au fost identificate 4 lipoame intratecale – 3 lipoame de filum terminale şi un lipom dural toracic (asociat unui sindrom plurimalformativ), două cazuri de coloană fixată, asociate cu siringomielie (asociate cu hemangioame în regiunea vertrebrală lombară) şi două lipo-mielomeningocel. A existat o corelaţie bună între imaginile ecografice şi cele RMN, sensibilitate 100%. Un caz de coloană fixată cu siringomielie şi un caz de lipo-mielomeningocel au beneficiat de urmărire ecografică timp de 3 luni pentru a se stabili momentul operator în funcţie de gradul de fixare al coloanei, respectiv creşterea masei tumorale intratecale. În ambele cazuri, a putut fi realizată o urmărire corectă ecografic, momentul operator fiind stabilit în colaborare cu medicul neurochirurg. Pacienţii au avut evoluţie favorabilă postoperator. Concluzii: Ecografia spinală poate furniza date de încredere dacă este efectuată până la vârsta de 3-4 luni. Pot fi identificate ecografic mobilitatea măduvei, dimensiunile acesteia, poziţia conus medullaris şi a filum terminale. În cazul pacienţilor cu risc de disrafism, ecografia a identificat cu exactitate leziunile ulterior confirmate de examenul RMN şi în cazuri selectate a permis urmărirea evoluţiei leziunii şi stabilirea momentului operator. Recomandăm folosirea ecografiei spinale ca primă linie de investigaţie în cazul pacienţilor cu risc de disrafism spinal închis, înaintea efectuării examenului RMN.Aim: The aims of our research were to establish the feasibility of the spinal ultrasound in the neonate and small infant, to identify the normal ultrasound findings at different ages, to identify the correlation between the ultrasound images and the spinal MRI in the case of spinal dysraphisms. Material and methods: In order to establish the feasibility of the spinal ultrasound and identify the normal findings 350 spinal ultrasounds were performed in normal term neonates. There were performed longitudinal and transverse sections in the cervical, thoracic, lumbar, and sacrococcygeal areas, using a linear probe with a frequency of 10 Hz. There were noted: the position and mobility of the spinal cord, the diameters of the cord and spinal canal (cervical, thoracic, lumbar), the position of the conus modular, the diameter of filum terminal, the presence of cysts of filum terminale or conus medularis. In order to establish the age until the spinal ultrasound can provide reliable images, there were reviewed the spinal ultrasound performed in patients in the follow-up programme for infants at risk. There were also investigated by ultrasound 40 cases of neonates at risk of occult spinal dysraphism, suggested by the presence of cutaneous stigmata, lumbosacral sinuses, median or paramedian masses, abnormalities detected in utero. The patients had also spinal MRI performed in order to confirm the abnormalities detected by ultrasound. In certain situations (see below) serial ultrasound was performed in patients with tethered cord or lipo-myelomeningocele in order to help to establish the optimal timing for surgery. Results: The level of the conus medullaris was identified to be situated at the level of L1 in 88 cases (25.1%), L1-L2 space in 203 cases (58%) and below L2 in 59 cases (16.8%). The thickness of the filum terminale was 1.8 cm(+ 0.5 cm). There were not identified spinal defects in the case of normal neonates, without stigmata. There were identified 5 cysts of filum terminale and 3 cases of ventriculum terminalis, with no pathologic significance. In the case of the patients in the follow-up programme, there were performed spinal ultrasounds in 36 patients. In 32 cases, the ultrasounds were performed until the age of 3 months, the intravertebral stuctures were visible at this age. In 4 cases, the ultrasounds were performed between 4 and 6 months; the ultrasounds performed at 4 months displayed the structures with sufficient accuracy, the intravertebral space was partially visible in one patient at 6 months and was not visible in the others. In 4 cases, the patients were referred to ultrasound after the age of 5 months, in these cases, the intravertebral structures could not be visualised. The indications for spinal ultrasound in case of risk of spinal dysraphism were represented by sacro-coccygeal sinuses -24 cases, hemangioma in verterbral or paravertebral regions – 6 cases, hyperpigmented areas in the vertebral region – 5 cases and lumbosacral tumoral masses – 2 cases. There were identified 4 cases of lipoma – 3 lipoma of filum terminale and one dural thoracic liopoma (associated with a plurimalformative syndrome), two cases of tethered cord associated with syringomyelia (associated with hemangioma in the vertebral lumbar region) and two lipo-myelomeningoceles. There was a good correlation between the ultrasound images and MRI findings, 100% sensitivity. In one case of tethered cord and one case of lipo-myelomeningocele serial spinal ultrasounds were performed for 3 months in order to help to establish the optimal time for surgery, in relation to the degree of fixation of the cord and the increase of the intrathecal tumoral mass. In both cases a correct ultrasound follows up could be undertaken, the optimal timing for surgery being established in coordination with the neurosurgeon. The patients had a favourable evolution after surgery. Conclusions: Spinal ultrasound can provide reliable data if it is performed until the age of 3-4 months. There could be identified: the mobility of the cord, the dimension of different segments, the position of conus medullaris and filum terminale. In the case of the patients with a risk of dysraphism, the ultrasound exactly identified the lesions confirmed further by MRI and allowed in selected cases the follow of the evolution of the lesion and help to establish the timing for surgery. We recommend the use of the spinal ultrasound as a first-line investigation in the case of patients with risk of closed spinal dysraphism, before the MRI

Foetal Intrapartum Compromise at Term : Could COVID-19 Infection Be Involved? A Case Report

The impact of the SARS-CoV-2 infection on pregnancy has been studied and many reports have been published, mainly focussing on complications and in utero transmission with neonatal consequences. Although the effects of other viruses on foetuses are well known, the impact of maternal COVID-19 during pregnancy is not completely understood. We report a case of acute foetal intrapartum hypoxia without other risk factors than maternal COVID-19 disease 2 weeks previous to birth at term. Placental histological changes suggested that the viral infection could have been the culprit for the unfavourable outcome during labour. The neonate was promptly delivered by Caesarean section. Neonatal intensive care was started, including therapeutic hypothermia. The procedure was successful, the evolution of the neonate was favourable, and she was discharged after 10 days. Follow-up at 2 months of life indicated a normal neurological development but a drop in head growth. The case raises the idea that pregnancies with even mild COVID-19 symptoms may represent the cause of neonate compromise in a low-risk pregnancy. An important follow-up in the neonatal period and infancy is required to identify and treat any subsequent conditions. Further long-term studies are necessary to identify a cause–effect relationship between COVID-19 pregnancies and the whole spectrum of neonatal and infant consequences

The role of spinal ultrasound in the diagnosis of spinal dysraphism – correlation with MRI examination

The paper presents the clinical, ultrasound and MRI appearances in the case of the closed spinal dysraphisms with a cutaneous/subcutaneous mass: lypomyelomeningocele, posterior meningocele and cervical meningocele. There is mentioned first the classification of these defects, then, for each type, a case example is presented, showing the clinical aspect of the lesion, the ultrasound features and the correlation of ultrasound with MRI images. The examples show a good correlation between ultrasound and MRI, entitling the ultrasound exam to be the first line of exploration in the case of this category of patients

Spinal ultrasound – Identification of the normal structures

The incomplete ossification of the spinal processes allows the ultrasonographic evaluation of the spinal cord and the adjacent structures in neonates and small infants. The paper describes the ultrasonographic examination of the spinal structures and the normal appearance of the spinal cord, the structures within the spinal canal, and the bony and muscular adjacent structures. Sagittal and axial sections at cervical, thoracic, lumbar, and sacral levels are described. There are also mentioned findings in the M mode and Doppler examinations

Vitamin D supplementation – still a subject of debate

Vitamin D is a standard vitamin supplementation for children in many countries, used mainly for preventing rickets. Many studies were published about the efficiency of vitamin D administration in children and adults for other pathologies besides rickets. Very often the results were contradictory, but nevertheless, more and more articles are published on this matter. There is no consensus for the effective vitamin D dosage nor for the vitamin D normal serum values. Both vitamin D deficiency and vitamin intoxication are dangerous for children. Recently some studies are showing controversial data that advise being more careful in prescribing vitamin D as a routine

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Improving the Quality of Electric Energy to Electric Arc Furnace

This paper presents a study of power quality problems created by an electric arc furnace (EAF) with eccentric bottom tap (EBT) at power system. The analysis have been done to EAF of 100 t capacity used for steel melting. Experimental results show this EAF is substantial source of electric disturbances, such as voltage fluctuations, flicker, harmonics, and unbalance between phases. Improvement of the quality of electric energy at EAF imposes a careful technical and economical analysis. Of all possible solutions for improvement of the power quality for an EAF (passive filter, STATCOM or SVC), SVC is the ideal solution

Respiratory Follow Up of the Premature Neonates—Rationale and Practical Issues

The aim of the review was to present the state of knowledge about the respiratory pathology in former premature neonates (children that were born preterm—before 37 weeks of gestation—and are examined and evaluated after 40 weeks corrected age) other than chronic lung disease, in order to provide reasons for a respiratory follow-up program for this category of patients. After a search of the current evidence, we found that premature infants are prone to long-term respiratory consequences due to several reasons: development of the lung outside of the uterus, leading to dysmaturation of the structures, pulmonary pathology due to immaturity, infectious agents or mechanical ventilation and deficient control of breathing. The medium- to long-term respiratory consequences of being born before term are represented by an increased risk of respiratory infections (especially viral) during the first years of life, a risk of recurrent wheezing and asthma and a decrease in pulmonary volumes and airway flows. Late preterm infants have risks of pulmonary long-term consequences similar to other former premature infants. Due to all the above risks, premature neonates should be followed in an organized fashion, being examined at regular time intervals from discharge from the maternity hospital until adulthood—this could lead to an early detection of the risks and preventive therapies in order to improve their prognosis and assure a normal and productive life. The difficulties related to establishing such programs are represented by the insufficient standardization of the data gathering forms, clinical examinations and lung function tests, but it is our belief that if more premature infants are followed, the experience will allow standards to be established in these fields and the methods of data gathering and evaluation to be unified