Tethered Cord Syndrome Research Articles

MP52-08 LOWER URINARY TRACT FUNCTION PRE- AND POST-UNTETHERING SURGERY FOR SECONDARY TETHERING IN PATIENTS WITH SPINA BIFIDA

You have accessJournal of UrologyCME1 Apr 2023MP52-08 LOWER URINARY TRACT FUNCTION PRE- AND POST-UNTETHERING SURGERY FOR SECONDARY TETHERING IN PATIENTS WITH SPINA BIFIDA Daisuke Gotoh, Kenta Onishi, Yosuke Morizawa, Shunta Hori, Yasushi Nakai, Makito Miyake, Kazumasa Torimoto, and Fujimoto Kiyohide Daisuke GotohDaisuke Gotoh More articles by this author , Kenta OnishiKenta Onishi More articles by this author , Yosuke MorizawaYosuke Morizawa More articles by this author , Shunta HoriShunta Hori More articles by this author , Yasushi NakaiYasushi Nakai More articles by this author , Makito MiyakeMakito Miyake More articles by this author , Kazumasa TorimotoKazumasa Torimoto More articles by this author , and Fujimoto KiyohideFujimoto Kiyohide More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Secondary tethering of the spinal cord occurs in 3–30% of patients with history of spinal cord repair of spina bifida. Tethered spinal cord syndrome is characterized by neuropathy that develops when the caudal end of the spinal cord is fixed and gets pulled as the spine grows. These patients show various symptoms of lower urinary tract dysfunction, including urinary incontinence, frequent urination, and dysuria. The main treatment is surgical release of the tethered spinal cord. We evaluated the effect of spinal cord untethering surgery on lower urinary tract dysfunction for secondary tethered spinal cord. METHODS: We enrolled patients with spinal cord retethering who underwent untethering surgery at the Department of Urology, Nara Medical University and Hoshigaoka Medical Center between January 1, 2010, and December 31, 2021. We retrospectively evaluated pre- and 6 months postoperative video-urodynamic findings of detrusor overactivity (DO), vesicoureteral reflux (VUR), bladder deformity (BD), maximum cystometric capacity (MCC), MCC/expected bladder capacity (EBC), and bladder compliance. RESULTS: Median age at retethering of the 19 participants included was 9 years. Nine patients had myelomeningocele and 10 had a spinal lipoma. Seventeen patients were managed with self-catheterization. DO was observed in six patients; it disappeared postoperatively in all of them. VUR was observed in three patients, and the severity reduced after surgery in two of them. The Ogawa classification grade of BD improved postoperatively in six patients (Figure 1). Marked postoperative improvement was also noted in MCC, MCC/EBC, and bladder compliance (pre- vs. postoperative MCC: 172.1±86.7 vs. 231.3±108.9 mL, p<0.0001; MCC/EBC: 63.8±27.3 vs. 72.7±28.4%, p=0.0131; and compliance: 9.1±8.6 vs. 13.7±12.8 mL/cm H2O, p=0.0098) (Figure 2). CONCLUSIONS: Release of the retethered spinal cord after primary repair improved urine storage function as assessed using video-urodynamics in patients with spina bifida. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e705 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daisuke Gotoh More articles by this author Kenta Onishi More articles by this author Yosuke Morizawa More articles by this author Shunta Hori More articles by this author Yasushi Nakai More articles by this author Makito Miyake More articles by this author Kazumasa Torimoto More articles by this author Fujimoto Kiyohide More articles by this author Expand All Advertisement PDF downloadLoading ...

Triple Threat: Spinal Dural Arteriovenous Fistula in Spinal Dysraphism and Tethered Cord Syndrome, a Case Report with Literature Review

Introduction: The incidence of spinal dural arteriovenous fistula (SDAVF) in patients with spinal dysraphism is exceedingly rare with fewer than 30 cases reported. We report such a case and discuss the etiology, diagnostic, and treatment challenges of such patients. Case Presentation: This is a 37-year-old gentleman with a history of myelomeningocele (MMC) repair at the age of 2 years who presented to us with worsening bilateral lower limb weakness and numbness. Clinical examination demonstrated affected motor and sensory functions from the level of L2. An MRI Lumbosacral revealed S3/S4 dysraphism with a tethered low-lying conus. A CT angiogram of the spine followed by a spinal angiogram confirmed the diagnosis of a SDAVF with feeders from the median sacral artery and other branches of the left internal iliac artery. He underwent angioembolization, following which we noted a residual SDAVF and hence underwent a difficult second-stage angioembolization to the right lateral sacral artery branch. The patient remained status quo on follow-up. Conclusion: SDAVFs occurring in spinal dysraphism requires a high index of suspicion to ensure the diagnosis is not missed or masked by co-existing tethered cord and dysraphism. These lesions should be managed in a multidisciplinary multimodal individualized fashion.

Spinal cord anomalies in children with anorectal malformations: a retrospective cohort study

PurposeFirst, to assess the number of spinal cord anomalies (SCA), specifically tethered spinal cord (TSC) in patients with anorectal malformations (ARM), identified with spinal cord imaging (i.e. spinal cord US and/or MRI). Second, to report outcomes after TSC treatment.MethodsA retrospective mono-center study was performed. All ARM patients born between January 2000 and December 2021 were included. Screening for SCA consisted of spinal cord US and/or MRI. Radiology reports were scored on presence of SCA. Data were presented with descriptive statistics.ResultsIn total, 254 patients were eligible for inclusion, of whom 234 (92.1%) underwent spinal cord imaging. In total, 52 (22.2%) patients had a SCA, diagnosed with US (n = 20, 38.5%), MRI (n = 10, 19.2%), or both US and MRI (n = 22, 42.3%), of whom 12 (23.5%) with simple, 27 (52.7%) intermediate, and 12 (23.5%) complex ARM types. TSC was identified in 19 patients (8.1%), of whom 4 (21.1%) underwent uncomplicated neurosurgical intervention.ConclusionsSCA were present in 22% of ARM patients both in simple, as well as more complex ARM types. TSC was present in 19 patients with SCA, of whom 4 underwent uncomplicated neurosurgical intervention. Therefore, screening for SCA seems to be important for all ARM patients, regardless of ARM type.Level of EvidenceLevel III.

Surgical treatment of tethered cord syndrome showed promising outcome in young children with short duration.

Aside from the severity, surgical interventions for the treatment of neurological dysfunctions remain controversial. This study aimed to find factors predicting the benefits of tethered cord syndrome (TCS) surgery. 80 children with TCS were included and followed up for pre- and post-operative factors along with neurophysiological analysis. Outcomes were assessed by univariate and multivariate analysis. Surgical treatment not only improved preoperative signs and symptoms in 79% of TCS patients but it showed to be an efficient procedure for the occurrence of future neurological defects. Univariate analysis also revealed that surgical intervention in TCS children (age <1 year) can modulate filar lipoma location and cutaneous abnormalities three months after surgery. Neurophysiological assessment revealed only 5.0% of surgical complications in TCS patients. Two patients had cerebrospinal fluid leakage, and two cases of CNS infection were detected. Surgical intervention is highly recommended for the prevention of neurological deficits in children with TCS. Electrophysiological monitoring revealed rare complications following the surgery.

Comparison of Ultrasonographic Findings between Patients with Tethered Cord Syndrome and Healthy Children.

Tethered cord syndrome (TCS) is a type of occult spinal dysraphism, which necessitates early detection as an essential component of patient management in reducing complications. This study aimed to compare the findings of spinal cord ultrasonography between TCS patients and healthy individuals. The current study is a case-control study of patients who were admitted to the Akbar and Ghaem Hospitals (Mashhad, Iran) in 2019. The study population comprised 30 children with TCS aged under two years old, and the control group included 34 healthy peers of the same age. The maximum distance of the spinal cord from the posterior canal wall was measured in millimeters using ultrasonography. Demographic and sonographic findings of each participant were recorded in checklists, which were then entered into SPSS software. P values less than 0.05 were considered statistically significant. The study included 30 children with TCS and 34 healthy individuals with a mean age of 7.67±6.39 months. TCS patients had a significantly shorter maximum distance of the spinal cord from the posterior wall of the spinal canal than the control group (1.75±0.62 mm vs. 2.79±0.76, P<0.001). After performing corrective surgery, the TCS patients indicated significant improvement in this interval (1.57±0.54 mm to 2.95±0.49 mm, respectively, P=0.001). In comparison to children without TCS, the spinal cord was substantially closer to the posterior canal wall in TCS patients. However, these outcomes were improved significantly in patients after surgery.

Tethered cord syndrome in KBG syndrome.

Tethered cord syndrome (TCS) is characterized by leg pain and weakness, bladder and bowel dysfunction, orthopedic malformations such as scoliosis, and motor deficits caused by the fixation of the spinal cord to surrounding tissues. TCS is surgically treatable and often found in conjunction with other syndromic conditions. KBG syndrome is caused by variants in the ANKRD11 gene and is characterized by short stature, developmental delay, macrodontia, and a triangular face. The current study explores the prevalence of TCS in pediatric KBG patients and their associated signs and symptoms. Patients with KBG were surveyed for signs and symptoms associated with TCS and asked if they had been diagnosed with the syndrome. We found a high proportion of patients diagnosed with (11%) or being investigated for TCS (24%), emphasizing the need to further characterize the comorbid syndromes. No signs or symptoms clearly emerged as indicative of TCS in KBG patients, but some the prevalence of some signs and symptoms varied by sex. Male KBG patients with diagnosed TCS were more likely to have coordination issues and global delay/brain fog than their female counterparts. Understanding the presentation of TCS in KBG patients is critical for timely diagnosis and treatment.

Co-occurrence of subcutaneous myxopapillary ependymoma, dermal sinus tract, and filum terminale lipoma: a review of the pathobiology of caudal spinal cord development and spinal cord tethering. Illustrative case.

Myxopapillary ependymoma (MPE) is typically benign and found in the conus medullaris and/or filum terminale, although rare cases of subcutaneous and extra-axial MPE have been reported. The co-occurrence of MPE, tethered cord syndrome (TCS) with lipoma of the filum terminale, and a dermal sinus tract is extremely rare, with only 6 reported cases in the literature. Here, the authors present the first case, to their knowledge, of an extra-axial, subcutaneous MPE co-presenting with TCS, lipoma of the filum terminale, and a dermal sinus tract and discuss the underlying pathobiology. A 14-month-old male who presented for evaluation of a dermal sinus tract underwent magnetic resonance imaging, which revealed a tethered cord with associated lipoma. At 14 months, the patient underwent spinal cord detethering with resection of his sacral dimple and sinus tract. Histopathological evaluation revealed an incidentally found MPE within the dermal sinus tract. The authors review the underlying biology of MPEs, tethered cord syndrome, and dermal sinus tracts, and explore possible points of convergence within the developmental pathways that may result in this unique concomitant presentation. Additionally, they suggest that extra-axial MPE may be underappreciated and underdiagnosed; this case suggests that extra-axial MPE may be only effectively diagnosed with histological studies.

Fetal Tethered Spinal Cord: Diagnostic Features and Its Association with Congenital Anomalies

Objective We assessed the frequency and type of associated congenital anomalies encountered with fetal tethered spinal cord (TSC) determined prenatally. Method A retrospective review was conducted based on the associated fetal abnormalities following diagnosis of low-lying fetal conus medullaris during the prenatal ultrasound. Results Of the 26 fetuses with low-lying conus medullaris, four were solitary TSC and 22 had TSC combined with associated congenital malformations, including four cases with spina bifida occulta, four cases with spina bifida aperta, one case with severe hydrocephalus, and 13 cases with multisystem congenital malformations. Among all the 13 cases with combined multisystem congenital malformations, four cases had vertebral defects, anal anomalies, cardiac defects, trachea-esophageal fistula, renal anomalies, and limb anomalies (VACTERL) syndrome, two cases had combined kidney development abnormalities, one case had cloacal exstrophy (OEIS syndrome), and six cases had chromosomal abnormalities (one case of chromosome 7q deletion, two cases of trisomy 13 syndrome, one case of trisomy 18 syndrome, one case of trisomy 9 syndrome, and one case of chromosome 4p deletion). Conclusions Low-lying conus medullaris found during prenatal ultrasound examination were often associated with neural tube malformations or multi-systemic complex developmental malformations. The frequency of chromosomal abnormalities was 23.1%.

Chronic Hydrocephalus and Tethered Cord Masquerading as Postconcussive Syndrome

We present a rare case of chronic hydrocephalus and tethered cord syndrome in a high-functioning asymptomatic college student. Her presentation was triggered by a fall, at which time, she developed subacute symptoms consistent with progressive increased intracranial pressure. After endoscopic third ventriculostomy for hydrocephalus, the patient presented with progressive bilateral lower extremity and sphincter symptoms, leading to spinal imaging and diagnosis of tethered cord syndrome with fatty filum. The patient was treated with tethered cord release and had a favorable long-term outcome. This case highlights the innocuous onset of 2 congenital diagnoses in adulthood seemingly associated with a mild traumatic injury. Furthermore, it shows classic imaging findings associated with chronic increased intracranial pressure, aqueductal stenosis, and tethered cord syndrome (preoperative and postoperative appearances), which serve an important educational role given the relate rarity of these coexisting diseases in adults.

Tethered cord syndrome in adulthood

Tethered cord syndrome in adulthood

Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism.

Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.

Urological Aspects of Spinal Dysraphism.

Micturition requires complex interplay involving bladder, peripheral neural network, spinal cord, and brain. Spinal dysraphism presents variety of neural lesions that may affect this interplay leading to neurogenic bladder. However, the diagnosis of neurogenic bladder in those with spinal dysraphism is often difficult and contrasted to other types of neurogenic bladder caused by complete neural lesions such as spinal cord injury or brain tumor. Typically, neurogenic bladder caused by spinal dysraphism shows lower motor neuron lesion and partial neural injury. However, upper motor signs can be seen with the occurrence of tethered cord syndrome and developmental immaturity of bladder control often complicated by fecal impaction. Thus, the diagnosis of tethered cord syndrome should be made cautiously. Several invasive and noninvasive diagnostic modalities could be applied for accurate diagnosis, preventing renal damage and controlling urinary incontinence. However, it should be borne in mind that no single study is definitive for accurate diagnosis, so it requires careful scrutiny in interpretation. The follow-up scheme of these patients should be determined to detect urological deterioration due to the development of tethered cord syndrome. Since the development of tethered cord syndrome shows diverse nature implicating urological and orthopedic issues, multidisciplinary collaboration is essential for comprehensive care.

A Novel Surgical Wrapping Duraplasty Procedure for Tethered Cord Syndrome Due to Terminal Lipoma―A Technical Report of Two Cases―

A Novel Surgical Wrapping Duraplasty Procedure for Tethered Cord Syndrome Due to Terminal Lipoma―A Technical Report of Two Cases―

The use of MRI in the study of patients with idiopathic scoliosis: a systematic review of the literature

Objective. To analyze the frequency of hidden neuraxial pathology in idiopathic scoliosis (IS), to substantiate the need for MRI in IS and to identify promising areas for the use of MRI in the examination of patients with IS.Material and Methods. The literature review was carried out using the PubMed and Google Scholar databases. Of the 780 papers on the research topic, 65 were selected after removing duplicates and checking for inclusion/exclusion criteria. As a result, 49 original studies were included in the analysis. Level of evidence – II.Results. According to modern literature, the main direction of using MRI in idiopathic scoliosis is the search for predictors of latent pathology of the spinal cord and craniovertebral junction. The frequency of neuraxial pathology in idiopathic scoliosis is 8 % for adolescent IS and 16 % for early IS. The main predictors of neuraxial pathology are male sex, early age of deformity onset, left-sided thoracic curve and thoracic hyperkyphosis. MRI in IS may be a useful addition to radiological diagnostic methods to identify risk factors and to study degenerative changes in the spine.Conclusion. MRI of the spine should be performed in the early stages of IS to detect latent spinal cord tethering. In type I Chiari anomalies, there is a possibility that early neurosurgery can prevent the development of scoliosis. The main signs of latent neuraxial pathology in IS are early progression of spinal deformity, left-sided thoracic curve, male gender and thoracic kyphosis over 40° according to Cobb.MRI can be used as an effective non-invasive tool in research aimed at identifying risk factors for IS, including helping to track early degeneration of intervertebral discs.

Prenatal assessment and pregnancy outcomes of foetal low-lying conus medullaris using 3D ultrasound

ObjectivesThis study aims to follow up on low-lying conus medullaris (CM) cases and explore the correlation between the CM location and the final prognosis. MethodsWe retrospectively collected 37 cases diagnosed with low-lying CM during pregnancy in the Peking University First Hospital from January 2019 to December 2020. The location of CM was confirmed by 3D ultrasonography, and clinical data, including postnatal outcomes, were recorded. When the conus medullaris was below L3 (excluding L3), it was diagnosed as low-lying conus medullaris, regardless of gestational age. The short-term postnatal outcome included assessment of symptoms and signs of motor and sensory neuron dysfunction.ResultsThe average gestational weeks of low-lying diagnosis was between 23 and 24 weeks. Among 37 cases, nine (24.3%) were complicated with spine dysraphism (3 cases of open spina bifida, 6 cases of tethered cord syndrome). Apart from 7 cases of pregnancy termination, the remaining 30 live births had a good prognosis in the short term, though 5 out of 6 cases of tethered cord syndrome underwent surgical release. The mean location of cases of open spinal dysraphism (n = 3) and those of closed dysraphism/tethered cord syndrome (n = 6) was at Lumber vertebra 5 (L5) and between L5 and Sacral vertebra 1 (S1), respectively, which showed statistical significance compared with the postnatally normal group. When we set Lumber 4.25 as the cut-off value to predict the diagnosis of spine dysraphism (mainly involving open spinal dysraphism and closed spinal dysraphism/tethered cord syndrome), the sensitivity was 66.7. At the same time, the specificity was 96%, along with the area under the curve (AUC) at 0.877.ConclusionThe second trimester finding of low CM is associated with spinal defects, mainly open spinal dysraphism and closed spinal dysraphism/tethered cord syndrome. Careful assessment of the fetal spine should be considered especially when the location of CM is lower than L4.

A Case Report of Lumbosacral Lipomyelomeningocele with Tethered Cord Syndrome

The objective is to describe a rare case of lumbosacral lipomyelomeningocele with Tethered Cord Syndrome. Tethered cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of spinal cord within the spinal column. A 7 years old girl child presented with lumbosacral swelling with non healing ulcer on foot and with weakness of lower limbs since childhood. MRI scan of lumbosacral spine suggest spinal dysraphism in L3-L5 vertebrae with lipomeningomyelocele from L2 to S2 levels with tethered low lying cord .The patient underwent surgical procedure. The majority cases of tethered cord syndrome are related to spinal dysraphism.Children with spinal dysraphism, especially those with lipomyelomeningocele, who may be associated with TCS, which may be asymptomatic at an early stage, require intensive follow-up care and observation.&#x0D; Keyword: Spinal dysraphism, neurological disorder, TCS, lipomeningomyelocele.

Gestational age-specific reference standards of low-lying conus medullaris level in fetuses: a prospective cohort study.

To explore the position change of fetal conus medullaris by ultrasound, and to propose gestational age-specific references for the lower limits of fetal conus medullaris level. We prospectively collected the imaging and clinical data of fetuses whose mothers accepted routine prenatal ultrasonic follow-ups in the Department of Medical Ultrasonics, Chinese PLA General Hospital, between November 2020 and April 2021. By assigning to the conus medullaris levels, calculating statistical data, and performing linear regression analysis, we determined the correlation between the conus medullaris level and gestational week, as well as between the 95th percentile of the conus medullaris level, i.e., the lower limit of the conus medullaris level, and gestational week. We included 1202 different fetuses at 17-40 gestational weeks in the study. Both the conus medullaris level and the 95th percentile of the conus medullaris level were linearly correlated with gestational week. We calculated the adjusted values of the lower limits of fetal conus medullaris levels, that is, the theoretical references of the lower limits, according to the linear regression equation, and composed a comparison table. The fetal conus medullaris position continues changing cranially with gestational weeks during the whole pregnancy. The conus medullaris of a term fetus should not lie below the L2 vertebra level at birth. We proposed reference criteria of fetal low-lying conus medullaris for each gestational week from 17 to 40weeks of gestational age, which potentially help prompt diagnosis and improve prognosis of fetal tethered cord syndrome.

Surgical treatment of tethered cord syndrome with sacral canal cysts: Analysis of 13 cases

TCS is a clinical manifestation of abnormal stretch of spinal cord, which needs to be solved urgently. To review and summarize the most recent surgical cases in our department involving a rare disease (tethered cord syndrome (TCS) with sacral canal cyst). From December 2015 to February 2018, thirteen patients with TCS and a sacral canal cyst, ranging in age from 8 to 53 years, were enrolled. There were eight males and five females in the group. A spine X-ray, CT, MR, lower extremity evoked potential, residual urine, and urodynamics were performed in addition to the standard preoperative examination. All patients underwent microsurgery while being electrophysiologically monitored. During the operation, Kirollos and Van-Hille graded the degree of tethered cord release, as well as Hoffman's neurological functional grading to assess efficacy and lumbosacral MRI observation of the sacral canal cyst recurrence. There were no deaths. The TCS was completely released during the operation, and the sacral canal cyst did not recur. Except for one patient who experienced increased postoperative symptoms, the symptoms or signs of the remaining patients improved to varying degrees, according to the Hoffman neurological function classification. In sacral canal cyst patients, intraoperative use of a surgical microscope and electrophysiological nerve function monitoring can effectively reduce spinal cord and nerve damage and improve surgical safety.

Intraoperative neurophysiological evaluation of central motor conduction time during an untethering surgery: a case report

Tethered cord syndrome is a congenital disease associated with abnormal stretching of the spinal cord and lumbosacral roots caused by a tight terminal filum. Untethering surgery is performed to minimize or prevent ongoing neurological deficits in the lower limbs, bladder, and bowel functions. As untethering surgery itself carries the risk of inducing additional neural injuries, intra-operative neurophysiological monitoring including electromyography, motor evoked potential (MEP), somatosensory evoked potential, and bulbocavernosus reflex is essential for improving functional outcomes after surgery. However, as MEP reflects the integrity of both the central and peripheral nervous systems, monitoring it alone is insufficient to differentiate between the neural damages of spinal cord and nerve roots. Herein, we report the first case of a child in whom both central motor conduction time and MEP were measured during untethering surgery to differentiate the location of neural injuries between the spinal cord and lumbosacral roots.

The influence of body position on cerebrospinal fluid circulation

Background. Cerebrospinal fluid (CSF) circulation consists of two components, a net flow and a pulsatile flow. CSF is generally believed to be produced through the ventricular choroid plexuses and absorbed in sites such as the subarachnoid granulations and nerve roots, contributing to the net flow. The pulsatile driving forces include cardiac vascular pulsation, respiration and muscular contraction.1 Measuring CSF flow in the upright posture is important because we spend most of our lifetime upright.&#x0D; Methods. Thirty asymptomatic volunteers (age: 22-72; 9 males, 21 females) were scanned in the upright seated and supine position on a 0.6 T multi-position MRI scanner (Fonar, New York, USA). CSF flow and spinal cord pulsation were imaged and quantified at the axial mid-C2 level with cine phase-contrast MRI.&#x0D; Results. In the upright posture, heart rate increased by 10%, and peak CSF diastolic flow decreased by 43% compared to the supine posture.2 In addition, the oscillatory volume of CSF exchanged between the spine and cranium decreased by 37% when going from supine to upright posture, consistent with a previous study.3 This could mean that the amount of time spent in different postures as we age may affect the efficiency of glymphatic brain waste clearance and development of neurodegenerative diseases. A less studied but diagnostically important aspect of CSF flow is the concomitant pulsation of spinal cord and central nervous system (CNS) tissue. For example, it is found that in Alzheimer’s Disease patients, the spinal cord at mid-C2 is pulsating much more in the mid to high frequency range (4 to 8 Hz) compared to normal older people in the supine posture. In the normal population, the mid-C2 spinal cord pulsates much less in the upright posture, with a 40% reduction of peak systolic velocity compared to the supine posture. Other postural differences include the more prominent appearance of nerve roots in the supine posture, shift of venous outflow from jugular veins to epidural/smaller veins, and the slimming of the neck when upright. It is also found that CSF flow is much more sensitive to aging in the upright than in the supine position. More specifically, as we age, heart rate change between postures diminishes and the upright peak systolic/peak-to-peak pressure gradient decreases. Since studies have shown that meditation can slow down brain aging, it would be beneficial to study its effect on CSF flow and the process of brain waste production and clearance.&#x0D; Conclusions. Besides delineating the many significant postural differences in CSF circulation, multi-position CSF imaging is also valuable in diagnosing various diseases such as Chiari malformation,4 Ehlers-Danlos syndrome and tethered cord syndrome in the lumbar spine. Often pathology that is not evident in the traditional supine imaging position can be visualized in other patient positions. Finally, a seminal study5 in rodents found that glymphatic transport is most efficient in the lateral recumbent position compared to supine or prone position, which concluded that posture must be considered in future diagnostic imaging procedures to assess CSF – interstitial fluid (ISF) transport in humans.