Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 52, Num. 3, 2004, pp. 403-404

Neurology India, Vol. 52, No. 3, July-September, 2004, pp. 403-404

Letter To Editor

Thecoperitoneal shunt in case of symptomatic anterior sacral meningocele

Khan AlokKR, Deb Sumit, Ray Dibyendu Kumar, Nag Bidyut Kumar

Neurosurgery Unit, R. G. Kar Medical College, 1, Kshudiram Bose Sarani, Calcutta - 700 004

Correspondence Address:Neurosurgery Unit, R. G. Kar Medical College, 1, Kshudiram Bose Sarani, Calcutta - 700 004

Code Number: ni04141

Sir,
An anterior sacral meningocele is a cerebrospinal fluid-filled unilocular or multilocular extension of the duramater and arachnoid mater out of the spinal canal through a defect either in the anterior sacral wall or antero-laterally through an enlarged vertebral foramen or coalesced foramina into the pelvic retroperitoneal and infraperitoneal space.[1],[2] Since its description by Bryant in 1837, only about 154 cases have been reported in the world literature.[3] There have also been reports of an anterior sacral meningocele being a part of the Currarino triad, which is a hereditary condition diagnosed when three abnormalities are noted: an anorectal malformation, an anterior sacral defect, and a presacral mass.[4]

An 18-year-old unmarried female patient presented with a history of gradually increasing difficulty in defecation for two years. On digital rectal examination, a mass was felt in the presacral region. No cutaneous stigma or any vertebral column abnormality was visible. Plain skiagram revealed the characteristic ′scimitar′ sign, characteristic of anterior sacral meningocele. Magnetic Resonance Imaging lumbar myelogram confirmed the presence of meningocele. As the meningocele sac appeared to be too large for direct ligation, a thecoperitoneal shunt was performed. Following surgery, the presacral mass could no longer be palpable by digital examination. Subsequent myelograms at 6 months and 1-year intervals revealed gradual reduction in the size of the meningocele sac, although there was no complete obliteration.

Adson advocated a posterior transsacral approach[5] for treating anterior sacral meningocele. Such an approach entails sacral laminectomy and intradural exploration to expose the anterior communication with the meningocele, aspiration of the meningocele through its pedicle, and closure of the defect with a primary suture repair or obliteration with a fascia graft.[6] Such a method of treatment is most suitable for a meningocele with a small pedicle.[2] The unsuitability of this approach in case of a meningocele with a wide neck and orifice has been reported.[7] The exposure of the meningocele sac by an abdominal or retroanal approach may allow a better exposure and subsequent closure of the pedicle. However, such an operation is more difficult and hazardous.[2] Laparoscopic management of anterior sacral meningocele has also been reported recently.[8]

In our patient, there was a wide communication of the meningocele sac with the spinal subarachnoid space and our simple alternative method treatment by a thecoperitoneal shunt proved to be effective. To the best of our knowledge, there is no report of such a procedure being attempted in the case of an anterior sacral meningocele.

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