PICTURE OF THE MONTH Occipital Encephalocele and Spinal Meningomyelocele in Same Patient: New Theories Hold True? Deepak Kumar Singh & Neha Singh Received: 11 February 2012 / Accepted: 30 March 2012 / Published online: 28 April 2012 # Dr. K C Chaudhuri Foundation 2012 A 3 d-old girl presented with history of two swellings on back of head and thoracic region since birth. Child was born to consanguineous marriage. Mother had not visited any ante-natal clinic and the baby was delivered at her home in a village. There was no other significant maternal or family history. On examination two swellings measuring approximately 5×5×5 cm were present on suboccipital area and back of thoracic region, respectively. Both swellings were cystic, compressible and non tender to touch (Fig. 1). Presence of neural elements was noted on trans-illumination. Skin over- lying both swellings was dysraphic. Baby was moving her both lower limbs and the anal tone was normal. There was no other congenital deformity. A diagnosis of occipital encephalocele and thoracic menin- gomyelocele with impending rupture was made. A MRI scan was done to confirm the diagnosis and patient was operated subsequently in view of threatened rupture. Multiple neural tube defects (NTD) in same patient have been reported very rarely. The search of literature revealed only 17 cases, in form of various combinations [1, 2], but such a classical case having occipital ence- phalocele and thoracic meningomyelocele has never been reported. The popular theory [3] of primary and secondary neuru- lation depicts that; there can only be two sites of NTDs- the anterior and posterior neuropores. The pathogenesis of multiple NTDs can be under- stood by multisite neural tube closure model [4], in which five closure sites have been shown to exist in the neural tube of human embryo. The multisite neural tube closure model suggests the existence of five sepa- rate closure points, or “zippers,” in normal neural tube in humans. Nakatsu et al. [5] examined human embryos in which the neural tube was closing grossly and histo- logically and observed that closure initiates at three sites: First site is future cervical region, widely accepted as an initiation site of neural tube closure; Second site is the mesencephalic- rhomboncephalon boundary and Third site is the rostral end of neural groove over the procencephalon where anterior neuropore closes. Some authors have suggested that fusion at cephalic level (second site) can be in two separate tracts in a Y- shaped manner [6]. This case is unique as it clearly holds the concept of zipper or at least three sites closure D. K. Singh (*) Department of Neurosurgery, Dr. RML Institute of Medical Sciences, Lucknow, India e-mail: gkp.deepak@gmail.com N. Singh Department of Radiodiagnosis, Chatrapati Sahuji Maharaj Medical University (Upgraded KGMU), Lucknow, India Indian J Pediatr (October 2012) 79(10):1393–1394 DOI 10.1007/s12098-012-0749-1