Image Presentation

Sonographic Duplication Artifact of the Spinal Cord in Infants and Children

Matthew J. Austin, BA, Eugenio O. Gerscovich, MD, Maria Fogata, MD, Marijo A. Gillen, MD, PhD, Bijan Bijan, MD

Objective. To describe the features of sonographic duplication artifacts that we have occasionally seen when imaging the spinal cord of infants and children, mostly with postrepair myelomeningocele. Methods. Sonography of the spine was performed for the evaluation of neonates with suspected spinal cord abnormalities and of older children in the follow-up of postrepair open-spine defects. Results. Each of our patients had a single spinal cord, but the duplication artifact was seen with 2 brands of scanners and with both linear array and vector array transducers. Conclusions. The finding of duplication artifacts when imaging the spinal cord of infants and children should be recognized as such and should not be misinterpreted as representing diastematomyelia or diplomyelia. Key words: diastematomyelia; diplomyelia; double image; duplication artifact; sonography.

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Received October 20, 2003, from the Department of Radiology, University of California, Davis Medical Center, Sacramento, California USA. Revision requested December 11, 2003. Revised manuscript accepted for publication January 21, 2004. Address correspondence and reprint requests to Eugenio O. Gerscovich, MD, Department of Radiology, University of California, Davis Medical Center, 4860 Y St, Ambulatory Care Center, Suite 3100, Sacramento, CA 95817 USA. E-mail: eogerscovich@ucdavis.edu.

he diagnostic utility of sonography depends on the unique acoustic properties of tissues to form useful images. However, as the ultrasound beam travels through various tissues, reflection and refraction of the ultrasound beam at acoustic interfaces with differing tissue velocities produce artifacts that are usually recognized and well understood.13 One wellknown artifact observed in the upper abdomen, lower abdomen, and pelvis is the ghost artifact, or, more appropriately, the double-image or split-image artifact.47 The split-image artifact results from refraction of the ultrasound beam through distinctive muscle-fat interfaces formed by the fusiform-shaped rectus abdominis muscles. In transverse scan planes at the midline, such refraction allows that some structures in the abdomen and pelvis may be completely duplicated.8 We found a similar artifact when imaging the spinal cord of infants and children at the midline in the transverse plane. This was most obvious in patients with postrepair myelomeningocele but was also seen to a considerably lesser extent in nonsurgical patients.

2004 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2004; 23:799803 0278-4297/04/$3.50

Duplication Artifact of the Spinal Cord in Infants and Children

Real-time sonographic examination was performed with 3 different scanners: Acuson 128XP/10 and Sequoia 512 (Siemens Medical Solutions, Mountain View, CA) and HDI 5000 (Philips Medical Systems, Bothell, WA). The scanners were equipped with linear or vector array transducers, generally at a frequency of 7 MHz, but occasionally at 5 MHz for the postsurgical patients and at 6 and 15 MHz (linear) and 8 MHz (vector) for nonsurgical patients.

Case Presentations
Duplication artifacts in 3 patients are illustrated in Figures 13 and described in their corresponding legends.

Discussion
Sonography is a well-established method of examining the spinal cord in neonates and infants.9,10 In this age group, the vertebral laminae are incompletely ossified at the midline, permitting transmission of the ultrasound beam without the acoustic shadowing that normally occurs with ossified vertebrae. Moreover, neonates and infants have taller intervertebral disks, which increase the intervertebral distance, thus resulting in a larger sonographic window. For the same reason, in older children with postrepair myelomeningocele, defects in the

posterior elements of the vertebral column allow successful examination of the spinal cord in that region. To the best of our knowledge, the duplication artifact of the spinal cord has never before been reported, yet this artifact has been seen in a number of cases at our institution. The cases presented here not only demonstrate that these duplication artifacts actually exist but also show that these findings are unrelated to the brand of scanner and type of transducer used. Because this artifact is analogous to what has been described in sonographic images of the abdomen and pelvis, it stands to reason then that these findings may be caused by a similar mechanism. When an ultrasound beam travels through an interface between media of different acoustic impedance, the beam refracts according to Snells law: sin 2/sin 1 = V2/V1, where 1 equals the angle of incidence; 2 equals the angle of refraction; and V1 and V2 are the velocities of sound in the 2 different media.11 A few different explanations have been proposed that use Snells law to describe the mechanism by which the double image is formed.47 Each theory also emphasizes that the anatomy of the anterior abdominal wall in the midline forms a unique muscle-fat interface through which ultrasound beams refract to produce the double-image artifact. Muller et al6 have suggested that the rectus abdominis muscles act as lenses, causing medial

Figure 1. Transverse sonograms of the spinal cord in a 3-year-old boy with postrepair myelomeningocele and tethering of the cord. The spinal cord appears artifactually duplicated (arrows) within the spinal canal (arrowheads) on 2 different scanners. A, Study performed on an Acuson scanner with a 5-MHz linear array transducer. B, Study performed on a Philips scanner with a 5-MHz linear array transducer.

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deviation of ultrasound beams in such a way to produce the double image (Figure 4A). Vandeman et al4 have suggested that the fat layer deep to the rectus muscles acts as a prism to refract the ultrasound beams. Because the rectus muscles are lens shaped, the muscle-fat interface deep to the rectus muscles forms a prismlike shape, which refracts the ultrasound beam to form the double image (Figure 4B). Some authors have suggested a role for the costochondral cartilage in the formation of the double image to explain artifactual duplications of the diaphragm, gallbladder, and posterior wall of the left cardiac ventricle when scanning through an intercostal approach.12,13 The anatomy of the posterior aspect of the thorax and lumbar region is comparable with the anatomy of the anterior abdomen in that the posterior paraspinal muscles (Figure 5) are similarly shaped and positioned, as are the rectus muscles of the abdomen (Figure 6). The similar anatomy suggests that any of the previously proposed explanations for the double image of the abdomen may play a role in the formation of the duplication artifact of the spinal cord as seen from a posterior midline approach. It seems likely that the interface between the paraspinal muscles and the fat layer deep to them causes the most significant refraction of the ultrasound beam. When scanning through the scar in postsurgical patients with anatomic distortion, the

Figure 2. Transverse sonogram of the spinal cord in a 7-year-old girl with postrepair myelomeningocele, obtained with a 5-MHz vector array transducer on an Acuson scanner. The spinal cord appears artifactually duplicated (arrows, 1 and 2) within the spinal canal (arrowheads).

described mechanisms to explain the duplication artifact seem more difficult to apply. Still, the artifact should be explained on the basis of refractive changes. Analogous to what has been shown in the abdomen, correction of the double-image artifact during the examination is easily achieved by sliding the transducer off the midline in either

Figure 3. Transverse sonograms of the spinal cord in a 2-month-old girl with postrepair myelomeningocele, obtained with a 7-MHz linear array transducer on an Acuson scanner. A, The spinal cord appears artifactually duplicated (arrows) within the spinal canal (arrowheads). B, The spinal cord (arrows) is confirmed to be single by sliding of the transducer laterally off the midline. The spinal canal is demarcated by the calipers.

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Figure 4. A, Approximate drawing representing the refraction of the ultrasound beam through the medial edges of both rectus muscles to converge at the level of the object. As the computer image is based on the expected path of the ultrasound beams, a double image is obtained. B. Approximate drawing representing the refraction of the ultrasound beam through the fatty prismlike area deep to the rectus muscles. a indicates the actual path of the ultrasound beam; asterisk, object; e, expected path of the ultrasound beam as interpreted by the scanner; F, fat prism; 1 and 2, duplicated image of the object; R, rectus muscle; and T, transducer.

Figure 5. The normal anatomy of the posterior thorax and upper lumbar region is comparable with the normal anatomy of the upper and lower abdomen. Arrowheads indicate the spinal canal; arrows, spinal cord; L, spinal lamina; and P, paraspinal muscle.

direction. Carpenter et al14 have suggested different methods to correct the distortional artifact by adjusting technical factors of the scanner using a priori information about the acoustic properties of the various layers. In summary, those who use sonography to image the spinal cord in infants and children should be aware of the possible duplication artifact in the transverse view and its potential to cause misdiagnosis. The duplication artifact of the spinal cord may be confused with longitudinal septation of the spinal cord (diastematomyelia; Figure 7) or true duplication of the spinal cord (diplomyelia). It may be seen with different brands of equipment and different transducer arrays. The alert operator will recognize the artifact and correct it by sliding the transducer laterally from the midline. Furthermore, the findings can be confirmed by sagittal views.
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Figure 6. Normal anatomy of the upper and lower abdomen. Arrows indicate the prismlike deep fatty area; and RM, rectus abdominis muscle.

Figure 7. Transverse sonogram of the spinal cord with a true duplication and tethering in a 6-month-old girl with postrepair myelomeningocele, obtained on an Acuson scanner with a 7-MHz linear array transducer. This study shows longitudinal septation of the spinal cord (arrows) within the spinal canal (arrowheads). The duplication of the spinal cord was shown to begin at the low thoracic level and to extend to the upper and mid lumbar regions, being dorsally adherent in the region of duplication.

References
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