Toe Walking in a Formerly Preterm Child: Is it Just Cerebral Palsy?

Spastic diplegic cerebral palsy (CP) is common among children born preterm and is a known cause of toe walking. By contrast, pediatric tumors of the conus medullaris are rare. We report the case of a 28-month-old formerly extremely preterm male with global developmental delay who presented with toe walking, constipation, and asymmetric hypertonia of the lower extremities. Brain imaging revealed periventricular leukomalacia, ex-vacuo ventricular dilation, and cerebellar dysplasia consistent with a diagnosis of CP secondary to perinatal injury. Lumbar spine imaging obtained due to his worsening constipation and pain while walking demonstrated an intramedullary, well-circumscribed, contrast-enhancing lesion in the conus medullaris. Post-resection pathology revealed a pilocytic astrocytoma. Following surgery, the patient had improved constipation and lower extremity tone, allowing him to walk with bilateral heel strike. His symptomatic improvement supported the contribution of the tumor to his bowel dysfunction and gait abnormality. This case of comorbid CP and conus pilocytic astrocytoma in a child with toe walking supports careful consideration of possible concurrent neurologic pathologies in the setting of atypical history and physical exam findings, such as pain while walking and bowel/bladder dysfunction. A higher degree of suspicion and consideration of parental report of pain while walking is especially important in cases in which the patient’s ability to report subjective symptoms, such as pain, subtle bowel/ bladder dysfunction, and sensory changes, is limited.