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During the early stages of compression impotence causes cures buy 20mg levitra oral jelly fast delivery, segmental demyelination occurs even in the absence of macroscopic changes erectile dysfunction drugs don't work order cheap levitra oral jelly. Edema, epineural fibrosis, and further thickening of the nerve occur with chronic compressive lesions. Damage to the nerve eventually becomes permanent as the myelin sheath cannot be repaired and axonal damage occurs. As such, impaired membrane permeability results in conduction block and wallerian degeneration. Not all fibers are equally susceptible, as large-diameter fibers resist compression less than small-diameter fibers. Centrally located fibers are typically spared at the expense of peripherally located ones. Median Nerve Entrapment Anatomy the median nerve originates from branches of the medial and lateral cords. Motor fibers are contributed by the medial cord primarily, whereas the lateral cord contributes mostly sensory fibers. The two branches unite superficial to the brachial artery, and the nerve and artery retain this close relationship throughout their course in the arm. The median nerve in the distal arm and the cubital fossa lie medial to the biceps and its tendon and medial to the brachial artery as the nerve courses over the brachialis muscle. At the level of the elbow, it lies behind the bicipital aponeurosis or lacertus fibrosis. The median nerve runs between these two heads and can be a source of compression neuropathy. As the median nerve courses through the two heads of the pronator teres, it typically gives off the anterior interosseous nerve from its lateral/ posterior surface. Emerging from the distal border of the pronator teres, the median nerve passes under the tendinous origin of the flexor digitorum superficialis muscle, and the nerve courses down the forearm posterior to the undersurface of the flexor digitorum superficialis, on the lateral aspect of the flexor digitorum superficialis tendons. Just proximal to the wrist, the median nerve lies deep in the space between the flexor digitorum superficialis and palmaris longus tendons. The median nerve then courses deep to the flexor retinaculum, accompanying the flexor tendons in the carpal tunnel. In the carpal tunnel, the median nerve lies lateral to the flexor digitorum superficialis to the middle finger and medial to the flexor carpi radialis, which is in its own compartment. After the median nerve emerges from the distal end of the flexor retinaculum, the nerve divides into the recurrent motor and sensory digital nerves. Entrapment neuropathies of the median nerve can occur at the supracondylar process, in the cubital fossa, or at the flexor retinaculum at the wrist. The supracondylar process is an anomaly that occurs in less than 2% of the population and is rarely symptomatic. It is a small bony prominence that arises 5 to 7 cm proximal to the medial epicondyle. The ligament of Struthers extends from the supracondylar process to the medial epicondyle, enclosing a foramen through which the median nerve and brachial artery and vein run. In the cubital fossa, the lacertus fibrosis, two heads of the pronator teres, and the flexor digitorum superficialis tendinous origin can all cause median nerve compression neuropathy. More distally, the carpal tunnel is the most common cause of all compression neuropathies in the body and, by far the most common compression neuropathy of the median nerve. This fibro-osseous tunnel is bounded laterally by the scaphoid and trapezium, medially by the hamate and pisiform, dorsally by the carpal bones and flexor tendons, and ventrally by the transverse carpal ligament. Presentation and Diagnosis Ligament of Struthers compression presents with pain over the elbow with weakness of pronation and hand grip. On exam, the surgeon may palpate a fibrous mass just proximal to the medial epicondyle along with weakness of the pronator teres, flexor carpi radialis, flexor pollicis longus, and digital finger flexion. Pronator weakness distinguishes ligament of Struthers compression from other syndromes. Nerve conduction studies show slowing of the velocity in the median nerve in the arm. Supracondylar process Ligament of Struthers Pronator teres Anterior interosseous nerve.

Axial loads in flexion are required for these fractures to occur in the straight thoracolumbar junction depression and erectile dysfunction causes order levitra oral jelly toronto. When surgical stabilization is deemed necessary erectile dysfunction treatment washington dc order levitra oral jelly 20 mg on-line, the choice of anterior column reconstruction or employment of longsegment fixation is dictated by the severity of the load sharing score. Distraction Injuries Flexion Distraction Injuries these injuries often involve the middle and posterior columns and sometimes all three columns. These fractures are unstable and are associated with neurologic injury if managed conservatively. Posterior long or short pedicle screw fixation is often employed for stabilization. Percutaneous pedicle screw fixation has been increasingly used for these injuries, especially in the presence of an osseous fracture component. Bony retropul sion occurs to different extents, causing varying degrees of spi nal canal compromise. The occurrence of associated neurologic injury is similarly variable, and its correlation with canal compro mise is often controversial. He was transferred to the emergency room, where an examination revealed 0/5 motor strength in the lower extremities. The patient underwent an emergency transpedicular corpectomy and anterior column reconstruction with an expandable titanium cage as well as posterior long-segment pedicle screw fixation. By the 1-year follow-up [lateral (d) and anteroposterior (e) X-rays], the patient had regained motor strength and was ambulating with a walker, but he still had a neurogenic bladder. He underwent an emergency exploratory laparotomy and repair of a liver laceration. Because the levels above and below the fracture are autofused, forming a large level arm, multiple points of fixation above and below the fracture are recommended, to provide op timal biomechanical stability and to prevent failure and screw pullout. The second step in managing thoracolumbar fractures is the selection of the appro priate approach and technique for stabilization when the decision to operate is made. Fracture Dislocations these are highly unstable three-column injuries that occur sec ondary to rotational shear forces, translational forces, or a com bination of both. A new classification of thora columbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Correlation between neurological deficit and spinal canal compromise in 198 patients with thoracolumbar and lumbar frac tures. Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise Treatment of traumatic thoraco lumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. Oper ative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. Flexion-distraction injuries of the thoracolumbar spine: open fusion ver sus percutaneous pedicle screw fixation. Hyperextension injuries of the thoracic spine in dif fuse idiopathic skeletal hyperostosis. However, more recent evidence suggests that medical management with intravenous antibiotics alone in certain instances may produce similar outcomes. Hematogenous spread accounts for half of the cases, contiguous spread accounts for one third, and no source is identified in the remaining cases. For example, in intravenous drug users and upper extremity infections, the thoracic spine is most often involved. It was often thought that the dorsal portion of the canal, due to its relatively larger volume and poorly vascularized epidural fat, was the most common site for infections to localize. The exact mechanisms by which thoracic epidural abscesses produce neurologic deficits remain unclear. Leading theories include a direct mechanical compression, an indirect vascular mechanism, or a combination of mechanical and vascular mechanisms. This explains the rapidity of onset and often irreversibility of neurologic deficits. The pathophysiology of neurologic deficits may differ among patients, and it seems prudent to conclude that vascular and compressive factors likely act in combination to produce the full clinical picture. Clinical Manifestations Nearly 50% of patients are misdiagnosed at initial presentation.

A microscope is brought into the surgical field for magnification and illumination erectile dysfunction pump prescription purchase 20 mg levitra oral jelly overnight delivery. A 2- to 3-cm vertical incision is made on the posterior aspect of the pharyngeal mucosa how to get erectile dysfunction pills buy discount levitra oral jelly on-line. The underlying muscles, including the longus colli and capitis, are swung laterally with a pharyngeal retractor. The minimally invasive microscopic transoral approach was later modified with endoscopic applications. In 2002, Frempong-Boadu et al3 described the endoscopic transoral technique, which provides superior visualization and illumination in the operative field. Patient Selection Patient selection depends on the type of disease, the location of the pathology, and the extensions of the lesion. Clival, midline, or paramedian lesions may be accessed with the endoscopic endonasal approach. Patients with significant basilar impression or a high-rising odontoid may also be managed with the endonasal operation. However, caudal extension may make the endonasal exposure unnecessary, as a downward trajectory may be limited by the nasal bone and the cartilaginous soft tissue superiorly. In particular, the transoral approach is well suited for lesions at the base of the clivus, in the odontoid process, or within 2 cm of the midline of the anterior C1 ring or the upper cervical vertebrae. Of note, patients with significant basilar impression may require resection of the anterior arch of C1 with the transoral technique, whereas a more rostral reach with the transoral technique may preclude C1 manipulation for an odontoidectomy. Protecting the C1 arch not only maintains structural stability but also protects medially coursing carotid arteries at the atlas level. The endoscopic transcervical approach provides wide axial exposure from the distal clivus through the entire cervical spine. Somatosensory evoked responses are established and monitored throughout the procedure. The mouth is opened a moderate amount with a Dingman selfretaining retractor with a tongue blade and soft palate retractor. The tongue blade is temporarily released every half hour to prevent congestion of the venous and lymphatic flow. A right-angled endoscope is then placed into the oral cavity for illumination and visualization. Guided with lateral fluoroscopy, a midline incision is made along the posterior pharyngeal wall from the approximation of the base of the clivus to the superior aspect of C3. The retropharyngeal and prevertebral tissues and muscles, including the longus colli and longus capitis, are dissected off the underlying bone. The exposure should not extend beyond 15 mm laterally to protect the eustachian tubes, hypoglossal nerves, and carotid arteries. Placement of self-retaining retractors ~ 15 mm from the midline provides adequate exposure of the lower clivus and atlantoaxial levels. Under endoscopic assistance, the drill is used to remove the anterior arch (and possibly the inferior aspect of the clivus) to exposure the dens. The application of a synthetic corticosteroid cream on the tongue and surrounding oral cavity reduces pressureinduced swelling. In addition, the endoscope confers several benefits over other transoral approaches. In perhaps the greatest advantage, the endoscope includes an angled lens that provides superior visualization through the restricted transoral corridors without extended incisions into the soft palate. This approximation may improve visualization into the operative corridors in comparison to the microscope. Indications As with the standard (microscopic) transoral approach, the endoscopic transoral technique is similarly indicated for pathologies within the anterior bony landmarks at the craniocervical junction, including the clivus, the anterior arch of the atlas, the odontoid process, and the upper cervical vertebrae. Thus, the approach enables exploration of extradural lesions causing compression or instability anywhere from the level of the interpeduncular fossa to the level of the spinomedullary junction. Endoscopic Endonasal Approach the endoscopic transnasal approach provides access to the upper cervical spine via the nasal cavity. They adopted the endoscopic endonasal approach to the craniocervical junction from the endoscopic endonasal skull-base surgeries.

Although the distal conus is not involved erectile dysfunction treatment yoga cheap levitra oral jelly 20 mg mastercard, it is often associated with a thickened or fatty filum terminale erectile dysfunction sample pills levitra oral jelly 20 mg on-line. However, unlike the dorsal variant, the transitional lipomas continue caudally to involve the conus. The irregular nature and large size of these lipomas can make it extremely difficult to define the anatomy, which inhibits safe resection. The name is derived from the variable nature of the anatomy and the indistinct relationship among the neural placode, roots, and lipoma. The neural tube is then open posteriorly and mesenchymal cells are able to enter the abnormal cleft. The mesodermal elements mature into fat that often connects the subcutaneous space to the distal spinal cord. Caudal lipomas, also referred to as terminal lipomas, are a result of an error in secondary rather than primary neurulation. Therefore, the lumbar and upper sacral nerve roots in addition to the dura and dorsal structures that are formed during primary neurulation are never affected. Often these lesions are found to have disorganized neural elements that suggest that they are due to incomplete or failed apoptosis. The lipoma may result in deviation or asymmetry of the upper portion of the gluteal crease; if the mass is subtle, an asymmetric crease may be the only external finding. However, as impairment progresses, the child may develop repeated urinary tract infections, incomplete voiding, or complete incontinence. Although the majority of patients with a midline lipoma are intact at birth, those patients with an asymmetric mass have a greater risk of neurologic impairment in the lower extremity ipsilateral to the lesion. Patients who have clinical findings typically show progressive asymmetric weakness with patchy sensory loss in the lower extremities. Clubfoot, with equinovarus and clawing of the toes, was the most common deformity. Multiple authors have reported arrested progression and even reversal of scoliosis after untethering. The patient may complain of low back pain and asymmetric pain in the legs that changes with time; occasionally, a Lhermitte sign is seen. Natural History and Surgical Outcome the decision to operate is clear in patients with symptomatic lumbosacral lipomas. Large series have shown that loss of neurologic function is unlikely to be regained completely in the majority of cases. However, due to the imperfect understanding of the natural history of this disease, there is still some controversy as to the best course for asymptomatic patients. Some authors have advocated a conservative approach after weighing the real risk of perioperative insult versus the possible risk of decline. Studies have shown that 33 to 40% of asymptomatic infants are likely to deteriorate over the course of 10 years. Due to the progressive nature of this disease and the irreversible nature of the deficits, prophylactic surgery was previously performed on the majority of asymptomatic patients. However, in a large series Pierre-Kahn et al2 reported that more than half of asymptomatic patients who underwent prophylactic surgery went on to have neurologic decline within 120 months of surgery. In 2010, Pang et al26 reported the long-term neurologic status of a group of 86 asymptomatic patients who had undergone total resection and a group of 116 patients who had undergone partial resection. The results for the group of patients with a partial resection were in keeping with the Pierre-Kahn study and with later natural history studies, with a progression-free survival of 43% at 12 years. However, the cohort of asymptomatic patients with total resections produces an impressive progressionfree survival of 98. The results of this study would suggest that prophylactic surgery is able to change the natural history of the disease only if a total resection is accomplished. Preoperative Evaluation All patients with a confirmed or suspected lumbosacral lipoma should undergo a full physical and neurologic evaluation.

One may lightly rest the drill on the spinous process (if present) for better control erectile dysfunction and diabetes ppt generic 20 mg levitra oral jelly free shipping. If a self-tapping polyaxial screw is not available medicare approved erectile dysfunction pump buy levitra oral jelly 20 mg overnight delivery, the dorsal cortex can be tapped using a 3. Once the bone graft is in place and the facet is denuded, the lateral mass screws can be inserted with anatomic guidance. In specific circumstances (commonly traumatic fractures), 16-mm screws can be elected if the anatomy can accommodate these dimensions. Similarly, in certain patients, only a 12-mm screw can be used given the proximity of the vertebral artery. Although bicortical penetration is advocated for more unstable spines, these patients have a greater risk of nerve root injury without offering better purchase. If posterior decompression is indicated, it is our preference to mark, drill, and prepare the screw sites before performing a laminectomy. After placing the screws, the appropriate-length rod is bent to conform to the lordosis of the cervical spine. Once the rods pass through the heads of all polyaxial screws, the rostral and caudal screws are secured with "set" screws and are tightened sequentially. Salvaging failed lateral mass screws can be accomplished with pedicle screw placements. Homeostasis is obtained with electrocautery, and a medium-sized Hemovac drain is placed below the fascia. The skin wound is reapproximated with staples, and adhesive dressing (Steri-Strips with Dermabond, Ethicon, Inc. With extensive knowledge of the surrounding anatomy and understanding of techniques, there is minimal risk of injury to neurovascular elements. Lateral mass screw fixation in the cervical spine: a systematic literature review. Posterior cervical arthrodesis and stabilization: an early report using a novel lateral mass screw and rod technique. Anatomic consideration for standard and modified techniques of cervical lateral mass screw placement. Modified Magerl technique of lateral mass screw placement in the lower cervical spine: an anatomic study. The need to add motor evoked potential monitoring to somatosensory and electromyographic monitoring in cervical spine surgery. Biomechanical study of screws in the lateral masses: variables affecting pull-out resistance. Characteristics of unicortical and bicortical lateral mass screws in the cervical spine. Using Dermabond for wound closure in lumbar and cervical neurosurgical procedures. Scheer, Shane Burch, and Christopher Pearson Ames Cervical spine pedicle screws were first used in 1964 by Leconte et al to treat traumatic spondylolisthesis of the axis. Cervical pedicle screws may be placed by free-hand techniques or image-assisted navigation. The accuracy of screw placement using a free-hand technique with or without fluoroscopy assistance is 12. The newest generation of image-assisted navigation, including the Iso-C3D system (Siremobil; Siemens, Erlangen, Germany) and the O-Arm and Stealth Navigation (Medtronic Inc. They had no neurovascular injuries, and thus all the screws were considered "clinically safe. This chapter presents the surgical techniques for free-hand and image-guided cervical pedicle screw placement. Patient Selection the aforementioned biomechanical advantages of cervical pedicle screws make them useful for patients requiring cervical fixation for reduction of translational deformities, and for fixed cervicothoracic kyphosis and multilevel cervical instability, which necessitate rigid posterior-only or circumferential fixation.

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The authors reported an 18% rate of unilateral hearing loss and an 86% local control rate depression and erectile dysfunction causes generic levitra oral jelly 20 mg visa. However impotence cures natural generic levitra oral jelly 20mg mastercard, this follow-up time is exceptionally short, and with longer follow-up times most patients may tend to suffer a recurrence. Plasmacytoma Plasmacytomas belong to the spectrum of B-cell lymphoproliferative diseases along with multiple myeloma. Moreover, these tumors may engulf vertebral vessels and expand into the pedicles in 20% of cases. This can be achieved via a transoral-transpalatopharyngeal approach or from a lateral extrapharyngeal-transcervical approach. However, occipitalcervical instrumented fusion with radiation therapy may be an alternative option. Patients most commonly presented with neuro-ophthalmologic symptoms and headaches. All 10 patients with chondrosarcoma underwent surgical excision via transcondylar, transoral, and anterior cervical approaches, among others. Future studies into adjuvant treatment modalities such as biologic agents and radiotherapy are needed. Dorsal approaches to intradural extramedullary tumors of the craniovertebral junction. Primary eosinophilic granuloma of adult cervical spine presenting as a radiculomyelopathy. Langerhans cell histiocytosis of the cervical spine: a single Chinese institution experience with thirty cases. Destructive osteoblastoma with secondary aneurysmal bone cyst of cervical vertebra in an 11-year-old boy: case report. Excision of an osteoid osteoma from the body of the axis through an anterior approach. Surgical outcomes of craniocervical junction meningiomas: a series of 22 consecutive patients. Surgical management of primary spinal hemangiopericytomas: an institutional case series and review of the literature. Hemangiopericytoma invading the craniovertebral junction: First reported case and review of the literature. Hemangiopericytoma in the central nervous system: treatment, pathological features, and long-term follow up in 38 patients. Tumors at the lateral portion of the C1-2 interlaminar space compressing the spinal cord by rotation of the atlantoaxial joint: new aspects of spinal cord compression. Retrospective analysis of peripheral nerve sheath tumors of the second cervical nerve root in 60 surgically treated patients. Chordoma: natural history and results in 28 patients treated at a single institution. Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Outcome of 132 operations in 97 patients with chordomas of the craniocervical junction and upper cervical spine. Chemotherapy of skull base chordoma tailored on responsiveness of patient-derived tumor cells to rapamycin. Proton therapy for skull base chordomas: an outcome study from the university of Florida proton therapy institute.

The patient is secured to the table erectile dysfunction following radical prostatectomy discount levitra oral jelly 20 mg amex, and the spinal level is marked on the skin using anterior and lateral fluoroscopy erectile dysfunction treatment vacuum pump order levitra oral jelly line. Note that the incision is usually made along the course of the rib two interspaces above the vertebral level to be addressed. The incision is performed from the anterior border of the latissimus dorsi to the midaxillary line, although it can be extended anteriorly to the costochondral junction. In this case a beanbag with a suction system is used to provide anteroposterior support. Finally, the rib is removed with a rib cutter while preserving the adjacent intercostal musculature and the neurovascular bundle on the pleural surface. In the case of a retropleural approach, the pleura is carefully dissected from its attachment to the inner surface of the ribs with "sponge dissectors. Although the retropleural technique is significantly more challenging (because the parietal pleura is thin and frail), if successfully performed it avoids the necessity of a chest tube postoperatively. When approaching lesions at the thoracolumbar transition it may be necessary to divide the diaphragm. Note the anatomic relationships of the sympathetic chain, as well as the disk spaces and neural foramina relative to the segmental vessels. Note than in order for the surgeon to achieve full access to the neural foramen through an anterolateral approach, the head of the rib must be removed. After identification of the rib head and the anterolateral portion of the vertebral body, intraoperative fluoroscopy is used to verify the appropriate level. Then, the segmental vessels of the level of interest (which course over the midportion of the vertebral body) are ligated in order to enable retraction of the great vessels from the anterior edge of the spine. There is some consensus in the literature that up to three contiguous segmental vessels can be ligated at one side with minimal risk of neurologic deficit due to vascular compromise of the spinal cord. During the anterolateral dissection of the vertebral body, a wrapped sponge in the form of a cylinder is used to progressively separate the great vessels from the spine. Conducting the dissection along the surface of the relatively avascular disk spaces helps to avoid bleeding. At this stage, care must be taken to preserve the structures running adjacent to the lateral aspect of the thoracic spine, such as the sympathetic chain and the thoracic duct. If the normal anatomy is not altered by tumoral pathologies or fractures, the concave portions over the spine represent the vertebral bodies, and the disks appear as more prominent and elevated portions. Next, the head of the rib is identified and resected to expose the underlying pedicle, the key landmark point to the location of the neural foramen, which can be palpated with a small blunt dissector. At this point the surgeon works on the vertebral bodies or disk spaces, depending on the pathology that is being addressed. Additional steps may include diskectomies or vertebrectomies, with the possibility of complete decompression of the anterolateral aspect of the spinal cord. In the cases of vertebrectomies, the endplates above and below are freed from disk material, and the anterior column is reconstructed with either a bone graft strut or a cage (which can be either a carbon-fiber or an expandable cage). For single-level corpectomies, anterior segmental instrumentation can be placed using a lateral plate or a dual-rod construct to obviate the need of posterior instrumentation. Additionally, after transpleural approaches, the parietal pleura overlying the spine is usually closed with interrupted absorbable sutures. In retropleural approaches, usually a suction drain is left near the spine to prevent postoperative paraspinal hematomas. It is important to emphasize that if an unintended durotomy a Closure After completion of the spinal portion of the procedure, a chest tube must be placed if the parietal pleural has been violated. The chest tube should be tunneled subcutaneously and brought out through a separate small incision one interspace away from the operative incision. After completion of the vertebrectomy and diskectomies at the level above and below (a), the anterior column is reconstructed with either a bone graft or a cage, and an anterolateral plating system is used for instrumentation (b). In the approaches to the thoracolumbar junction in which the diaphragm has been opened, this muscle is closed, with special care to match its correspondent portions in an attempt to restore, as best as possible, its normal contraction pattern. If only one rib has been removed, it is usually possible to partially reapproximate the adjacent ribs with a few sturdy sutures around them. Finally, the latissimus dorsi is reapproximated, the subcutaneous tissue is closed, and the skin is closed with a subcuticular running stitch and steri-strips. In comparison to these last two approaches, the lateral transthoracic approach had also the highest rate of reoperation (3. Despite such a morbidity profile, which includes a procedurespecific complication rate of 11.

Myxopapillary ependymomas tend to be more aggressive in children; therefore erectile dysfunction generic drugs levitra oral jelly 20 mg online, their prognosis is somewhat worse even with total gross excision erectile dysfunction onset cheap levitra oral jelly online mastercard. A laminectomy is performed over the lesion using radiographic confirmation of the level, if necessary. The use of a laminotomy can be considered in an attempt to increase the integrity of the spine postoperatively. With the bone removed, the lesion usually can be appreciated through the intact dura mater. The neoplasm itself is usually hemorrhagic, soft, and bluish gray, causing the nerve roots to be displaced laterally. Adhesions from the capsule Indications and Contraindications the indication for surgery is the presence of tumor in the thecal sac, with imaging indicative of myxopapillary ependymoma. There are no significant contraindications to surgery in a patient with stable cardiopulmonary status. A patient presented with a mass filling the lower lumbar and sacral spine, which is apparent on this midsagittal T1-weighted magnetic resonance imaging scan of the lumbar spine. In addition to maintaining the physical integrity of the roots, the vascular supply to these small structures must be maintained. Slowly working around the circumference of the lesion, dealing with points of adhesion, is the best option available. The further caudally the surgeon progresses, the fewer the nerve roots and the easier the dissection. Postoperative Care the standard postoperative care for spinal surgery is given, including monitoring urinary output, providing pain control, and starting physical therapy. Most patients are maintained in a relatively flat position for a few days to enable the best healing of the dura mater. Such complications can be minimized with strict surgical technique including a watertight dural closure with or without duraplasty and attention to bony removal or replacement. Conclusion Myxopapillary ependymomas are slow growing tumors that are often more aggressive in children. Surgery is indicated, with care taken not to allow tumor spread outside of the capsule. Ependymomas of the filum terminale in childhood: report of four cases and review of the literature. Myxopapillary ependymoma of the conus medullaris and filum terminale in the pediatric age group. Ependymoma of the cauda equina region: diagnosis, treatment, and outcome in 15 patients. Myxopapillary ependymoma: correlation of clinical and imaging features with surgical resectability in a series with long-term follow-up. Since its original description in the 1950s, this dis order has become more frequently diagnosed because of the increased ease of diagnosis and an expanded definition of the pathology. The recognition of the association of a thickened and taut filum terminale with other forms of occult spinal dysra phism (such as lipomyelomeningocele and split cord malforma tion) has improved the surgical outcome of numerous patients. Sectioning of the filum terminale is a simple and safe procedure that should be employed at the time the diagnosis is made. It is char acterized by excessive tension on the distal spinal cord by a thickened or inelastic filum terminale. The conus usu ally assumes a low position within the spinal canal reflective of its anticipated position. However, in an extremely small subset of patients, the conus may be located at a normal position. Re gardless of position, excessive tension is applied to the spinal cord causing neurologic dysfunction and possibly pain. Traction on the caudal cord results in decreased blood flow causing met abolic derangements that culminate in motor, sensory, and uri nary neurologic deficits. Imaging usually demonstrates a lowlying conus medullaris or a fatty infiltrated filum terminale.