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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

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

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.


1.Tostain J, Perraud Y, Preynat P, et al. Anterior sacral meningocele with urologic manifestations. Report of 3 cases. Prog Urol 1992;2:464-71.  Back to cited text no. 1    
2.Wilkins RH, Odom GL. Anterior and Lateral Spinal meningoceles. In: Handbook of Clinical Neurology, Vol. 32, Vinken PJ, Bruyn GW. Ed. Elsevier / North-Holland Biomedical Press, Amsterdam 1978:193-230.  Back to cited text no. 2    
3.Samuel D, Puvaneswary M. Anterior sacral meningocele. Med J Malaysia 1989;44:243-7.  Back to cited text no. 3    
4.Gaskill SJ, Marlin AE. The Currarino triad: Its importance in pediatric neurosurgery. Pediatr Neurosurg 1996;25:143-6.  Back to cited text no. 4    
5.Adson AW. Spina bifida cystica of the pelvis: Diagnosis and surgical treatment. Minn Med 1938;21:468-75.  Back to cited text no. 5    
6.Villarejo F, Scavone C, Blazquez MG, et al. Anterior sacral meningocele: Review of literature. Surg Neurol 1983;19:57-71.  Back to cited text no. 6    
7.Hino A, Taketomo S, Iwasaki T. Treatment of anterior sacral meningocele- case report. Neurol Med Chir Tokyo 1993;33:700-2.  Back to cited text no. 7    
8.Clatterbuck RE, Jackman SV, Kavoussi LR, et al. Laparoscopic treatment of an anterior sacral meningocele. Case illustration J Neurosurg 2000;92:246.  Back to cited text no. 8    

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