Abstract A 5-day-old male neonate presented with a palpable lumbar region swelling, leading to the suspicion of a neural tube defect (NTD) or other spinal abnormalities. The infant was born through cesarean section and appeared well-nourished, alert, and interactive with no neurological deficits or signs of infection. Brain screening using ultrasound and head magnetic resonance imaging (MRI) ruled out hydrocephalus and Arnold–Chiari malformation. Spinal imaging using MRI revealed a terminal syrinx in the conus medullaris, which was not apparent on clinical examination. Considering the potential complications and future neurological deterioration, a syringostomy was performed. Neonatal back swellings can be challenging diagnoses due to their broad spectrum of pathologies, including NTDs and terminal syringes. Terminal syringes involve the conus medullaris and cauda equina and may present as a palpable back swelling. These infants are typically asymptomatic at birth but can develop neurological deficits over time. MRI is the gold standard for evaluating suspected NTDs or terminal syringes due to its high resolution, multiplanar imaging capabilities, and lack of ionizing radiation. Ultrasound and computed tomography scans have limitations in diagnosing terminal syringes accurately. Early diagnosis and intervention are crucial to prevent potential complications and improve outcomes for these patients. The management strategy depends on how severe the underlying condition is. For infants without symptoms, close monitoring is recommended. If the baby shows symptoms or is at high risk, surgery can be considered. Syringostomy involves placing a shunt to drain cerebrospinal fluid from the syrinx into the abdominal cavity, reducing pressure and potentially improving neurological function. In conclusion, neonatal back swellings, particularly those caused by terminal syringes, require a thorough diagnostic evaluation and close follow-up. MRI is an essential diagnostic tool due to its high resolution and ability to delineate intracranial and spinal structures effectively. Early diagnosis and intervention can improve outcomes for these patients and prevent complications. Clinicians should maintain a high index of suspicion for terminal syringes in neonates with back swellings and pursue appropriate diagnostic tests, such as MRI, to ensure accurate diagnosis and timely management.
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