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|LETTER TO EDITOR
|Year : 2017 | Volume
| Issue : 1 | Page : 214-216
Spinal dysraphism with tripedus: A child with three legs
Shaam Bodeliwala1, Daljit Singh1, Hukum Singh1, Mohammad Iqbal1, Atul Agarwal1, Priyanka Khurana2
1 Department of Neurosurgery, G. B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
2 Department of Anaesthesia, G. B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi, India
|Date of Web Publication||12-Jan-2017|
Dr. Shaam Bodeliwala
Department of Neurosurgery, G. B. Pant Institute of Postgraduate Education and Research (GIPMER), New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bodeliwala S, Singh D, Singh H, Iqbal M, Agarwal A, Khurana P. Spinal dysraphism with tripedus: A child with three legs. Neurol India 2017;65:214-6
An accessory limb associated with spinal dysraphism is rare with only a few cases reported so far. However, its actual incidence is unknown. There are many hypotheses regarding the embryogenesis of an accessory limb. It may be a primary mesodermal defect involving paraxial mesoderm or a failure of regression of limb bud of a conjoined twin (rachipagus). As it occurs as a result of deranged embryogenesis, it is commonly associated with other malformations including vertebral body malformations, spina bifida, clubfoot, anorectal malformations, accessory pelvis, or genitalia. Here, we report a case of an accessory limb arising from midline dorsal region, attached to the lumbar vertebral column. This was associated with a meningomyelocoele protruding into the accessory limb as well as a subcutaneous lipoma.
A one-and-a-half year old female child presented with an accessory lower limb at the lower back growing with the growth of the child. The child was born to a 25-year-old lady after a nonconsanguineous marriage. Her antenatal and postnatal periods were uneventful. Antenatal ultrasonographic examination was not performed as per recommendations; however, the 11 and 18 week antenatal ultrasonographic examinations failed to detect any abnormality. The child was born by a normal vaginal delivery at home. At birth, the baby was healthy with a finger size projection arising from the lower back. She also had a left club foot. This appendage kept growing to attain the current size (14 cm). At presentation, the child had become conscious of the appendage and her mother had problems in dressing her. There was neither previous history of twins being born nor any congenital anomalies prevalent amongst members in the family. There was no history of maternal illness, drug intake, or radiation exposure during pregnancy. The child completed the entire recommended immunization.
Clinical examination revealed an accessory lower limb arising from the back at the level of L2 and L3 vertebrae. The accessory limb showed a partially developed foot with syndactyled toes and nails [Figure 1]. The limb measured approximately 14 cm in length. No evidence of any neurological deficit was noted. She also had left-sided congenital talipus equinovarus (club foot). The patient could walk without support, and other developmental milestones were normal. X-ray and computed tomography showed a soft tissue appendage with rudimentary bones attached to the L2-L3 vertebrae, appearing like bones of the lower limb [Figure 2]. Magnetic resonance imaging (MRI) confirmed the meningomyelocele with multilevel spina bifida [Figure 3]. The patient underwent excision of the accessory limb along with detethering of the cord and dural repair [Figure 4]. The proximal bone of the accessory limb was firmly adhered to the posterior elements of the L2 and L3 vertebrae. The postoperative period was uneventful, and MRI showed no residual accessory bone or dural sac.
|Figure 1: Photograph showing the accessory limb with the magnified view of the syndyctyled toes and nails (at the left lower corner)|
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|Figure 2: (a) Lateral view X-ray, and (b) non-contrast computed tomography with three-dimensional reconstructed images show the soft tissue mass (a cutaneous appendage) with rudimentary bones (shown by arrows) appearing like an underdeveloped limb|
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|Figure 3: Magnetic resonance (T2 weighted) images revealed the dural sac protruding into the accessory limb containing a part of the spinal cord and roots|
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|Figure 4: Intraoperative photograph showing the neural tissue (shown by an arrow) entering the dural sac which has been opened up. Here, the dural sac was protruding into the base of the accessory limb, which was covered with lipomatous tissue|
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Spinal dysraphism is a broad term depicting the defect in closure of the caudal neuropore, occurring in the second to sixth week of gestation. The incidence of spinal dysraphism has been decreasing in developed countries; however, it is still a major problem in developing countries. Incidence of spinal dysraphism in India is 1.9 per 1000 births. Some of the closed spinal dysraphism with secondary neurulation defect are generally associated with mesodermal anomalies such as an accessory limb or a tail-like structure containing mesenchymal tissue covered with skin (human tail). There are reports suggesting its association with fully formed organs, such as an ectopic breast and supernumery ribs, or differentiated tissues, such as salivary glandular, renal, intestinal or respiratory tissues.,, The first case operated for an accessory limb was reported by Jones and Larkin in 1889; however, earlier reports of supernumerary limbs have been noted. This condition has been given different names over time, including heterotopic redundancies, dysraphic appendages, polymelia, tripedus, heteropegus, aborted twinning, and rudimentary or aborted accessory limb.
There are different hypotheses postulated for the development of an accessory limb with spinal dysraphism. Solak et al., believed in fusion hypothesis. This hypothesis suggests that an accessory limb represents a failure of regression of the limb bud of the underdeveloped fused twin. Krishna et al., supported Gardner's theory for the development of accessory appendages, which suggested an overexpansion and subsequent rupture of the neural tube under the intact cutaneous ectoderm causing the dispersion of neural fluid and infiltration of mesodermal tissue, leading to an anomalous mesenchymal development. One theory proposed that it is a primary mesodermal defect involving para-axial mesoderm and limb bud whereas another theory suggested early splitting of the limb bud. None of the theories have been proven yet. Bayri et al., suggested that an accessory limb is associated with different types of neural tube defects, i.e., spinal lipoma (50%), meningocele (36%) or myelomeningocele (14%). It is most commonly found in the thoracic-interscapular region (35%) followed by the lumbar (22%), sacral (14%), and cervical (7%) regions. Most commonly, female infants are affected, as in our case. Such anomalies have also been identified with anorectal malformations, ectopic intestinal loops, and rudimentary external genitalia. Hence, these patients have to be completely investigated for associated congenital anomalies and treatment should be offered to them for these anomalies as well as for cosmetic concerns.
This article is dedicated to Francesco Lantini (1884), a famous “three legged football player,” who worked in a circus and made people laugh with his deformity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]