Successful Delayed Elective Separation of Pygopagus Conjoined Twins With Shared Spinal Cord and Dura in a Resource-Limited Setting: A Case Report.

Conjoined twins are a rare consequence of aberrant monozygotic twinning; one of the varieties is pygopagus twins, which are fused at the sacral region and may involve complex neural and dural sharing. We report a case of female pygopagus conjoined twins with shared spinal cord and dural sharing who underwent successful delayed elective separation at 6 months of age in a resource-limited tertiary care setting. Initial imaging revealed sacral deficiency, dural fusion, and spinal cord involvement without bony fusion. Surgery was postponed to allow nutritional optimization and adequate tissue growth. Nutritional readiness and local tissue adequacy were assessed through longitudinal clinical evaluation of weight-gain velocity, visceral protein sufficiency, and dermal mobility relative to pelvic landmarks, without relying on mechanical tissue expanders. Under general anesthesia, meticulous microsurgical separation of the fused dura and neural elements was performed, followed by watertight dural closure. Separation was accomplished without intraoperative neurophysiological monitoring, relying entirely on direct magnification and stepwise dissection. The postoperative course was largely uneventful except for transient pneumonia in one twin. Both infants were discharged on postoperative Day 12 in stable condition with intact neurological function. Delayed planned separation with multidisciplinary coordination and meticulous surgical technique can result in favorable outcomes, even in resource-constrained settings lacking advanced neurophysiological mapping facilities.