Tethered cord syndrome: an updated review

Surgical volume of simple tethered spinal cord releases: review of a large pediatric neurosurgical service experience

OBJECTIVE

The aim of this study was to retrospectively review, from a single busy pediatric neurosurgical service, a consecutive series of patients who had undergone surgery for a simple tethered spinal cord, which was defined by a thickened or fatty filum terminale with a normal conus. The hope was to contribute to benchmark data regarding the expected frequency of surgery for this condition.

METHODS

The authors reviewed the electronic medical records of every patient with diagnosed simple tethered spinal cord, defined on spinal MRI as a thickened (> 2 mm in diameter) or fatty filum terminale, and who had undergone primary filum section at Boston Children's Hospital between 2005 and 2011.

RESULTS

A total of 208 patients met the study inclusion criteria. At the time of surgery, patients ranged in age from 0.4 to 19.8 years. One hundred forty-four (69%) patients were symptomatic with one or more of the following: bowel/bladder dysfunction, 94 (45%); neurological dysfunction, 49 (24%); scoliosis, 44 (21%); or back pain, 44 (21%). Sixty-four (31%) patients were asymptomatic and were operated on prophylactically when filum pathology was discovered during the course of a workup for clinical syndromes such as anorectal anomalies and/or suspicious cutaneous lesions. No patients in this series were operated on if they had normal MRI studies, defined as a conus tip no lower than L3 and no distal tethering lesion visualized. Over the study period, approximately 1000 major surgical cases were performed in the department every year, only 30 of which were simple detethering procedures, representing well under 5% of the service's operative volume and approximately 5 cases per surgeon per year. Clinical follow-up, available at a postoperative interval of 6.6 ± 3.8 years, demonstrated that approximately 80% of patients symptomatic with bowel or bladder involvement or neurological dysfunction had improvement or relief of their symptoms and that none of the patients treated prophylactically experienced new-onset symptoms that could be related to spinal tethering.

CONCLUSIONS

Simple detethering procedures were relatively uncommon in an active, well-established pediatric neurosurgical service and represented less than 5% of the service's total case volume per year with an average of 5 cases per surgeon per year. No patients with normal MRI studies were operated on during the study period.

Retethering after transection of a tight filum terminale, postoperative MRI may help to identify patients at risk

PURPOSE

Retethering after transection of a tight filum terminale (TFT) deemed to be a rare and usually only years after initial surgery occurring complication. Possible perioperative factors that might influence the retethering rate or help to allow a prognostic risk assessment are still poorly investigated. The aim of this study was to analyze our patient cohort who underwent a TFT transection by assessing clinical outcome, retethering rate, and pre- and postoperative MRI studies.

METHODS

All consecutive patients undergoing transection of a TFT from January 2011 to December 2018 were evaluated. Inclusion criteria were defined as exclusive TFT intervention and a minimum follow up period of 1 year. Epidemiological data, treatment modalities, complication characteristics, and MRI studies were recorded and analyzed.

RESULTS

A total of 58 patients met our inclusion criteria. The retethering rate in our patient cohort was 5.2% (3/58); one of the three patients developed two episodes of a retethering. Patients with an unchanged conus level, no improvement in the syringomyelia, and an unchanged thickness of the spinal cord postoperatively seem to have a significant higher risk to develop a retethering episode in the follow-up.

CONCLUSION

Retethering after transection of the filum terminale did occur more often than expected. Certain existing factors on the routine postoperative MR images may help to identify patients with an increased likelihood to develop a retethering episode. These results may contribute to improve the follow-up for patients after transection of a TFT and may facilitate adequate treatment.

Incidence of Occult Spinal Dysraphism Among Infants With Cutaneous Stigmata and Proportion Managed With Neurosurgery: A Systematic Review and Meta-analysis

IMPORTANCE

Occult spinal dysraphism (OSD) is the most common congenital spinal anomaly. Cutaneous anomalies such as skin dimples or deviated gluteal folds are well known as stigmata of OSD and are indicators for further evaluation; however, the association between cutaneous anomalies and OSD has not been systemically evaluated.

OBJECTIVE

To evaluate the incidence of OSD and the proportion of OSD cases managed with a neurosurgical intervention among neonates or infants with various cutaneous stigmata.

DATA SOURCES

PubMed and Embase databases were searched for studies published up to July 25, 2018, that evaluated the proportion of OSD cases in neonates or infants with cutaneous stigmata. Search terms included ultrasound, dysraphism, dimple, and infant or neonate. The search was limited to English-language publications.

STUDY SELECTION

Two reviewers selected the studies evaluating the incidence of OSD among neonates or infants with cutaneous stigmata.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data extraction were followed. Pooled proportions of OSD cases and OSD cases that were managed with a neurosurgical intervention were obtained using the generalized linear mixed model and maximum likelihood method.

MAIN OUTCOME AND MEASURES

The pooled incidence of OSD and OSD cases managed with neurological surgery among patients with cutaneous stigmata was the primary outcome. This outcome was also evaluated in each subgroup, and heterogeneity was explored using subgroup analysis.

RESULTS

A total of 15 studies, involving 6558 neonate or infant patients with various cutaneous stigmata, were included. The pooled proportion of OSD cases among the patients with cutaneous stigmata was 2.8% (95% CI, 2.1%-3.8%; I2 = 51.6%), and the proportion managed with neurological surgery was 0.6% (95% CI, 0.3%-1.3%; I2 = 66.4%). Cases with combined stigmata showed a significantly higher association with OSD than those with a single stigma (10.5% [95% CI, 6.9%-15.8%] vs 2.3% [%, 95% CI, 1.5%-3.5%]; P < .001). The pooled proportion of OSD cases among patients with an atypical dimple was significantly higher than among those with simple dimple (8.8% [95% CI, 4.5%-16.6%] vs 0.6% [95% CI of 1.4%-2.1%]; P = .001).

CONCLUSIONS AND RELEVANCE

The proportion of OSD in healthy, asymptomatic patients with midline cutaneous stigmata was low, and the proportion of patients who underwent a neurosurgical intervention was even lower. However, a careful evaluation as well as potential spinal magnetic resonance imaging is recommended for neonates or infants with combined stigmata or an atypical dimple for possible high-risk lesions.

Spinal cord anomalies in children with anorectal malformations: Ultrasound is a good screening test

PURPOSE

The purpose of this study is to correlate spinal ultrasound (US) and magnetic resonance imaging (MRI) findings in patients with anorectal malformations (ARMs).

METHODS

A retrospective analysis of records was performed for children with ARM presenting to two major pediatric hospitals between 2009 and 2017. The primary outcome analyzed was detection of spinal cord anomalies. Spinal US was performed up to 4 months and MRI within the first year of life. The conus medullaris was considered normal if it had a tapering contour and terminated at or above the Lumbar 2-3 disk space.

RESULTS

One hundred ninety-three patients with ARM presented during the study period with a slight male preponderance (108, 56%). Spinal imaging was performed in 157(82%) - 137(87%) had US, 64(41%) had MRI and 44 (28%) had both. Of the 44 who had both; US was abnormal in 25 children-confirmed by MRI in 20 (80%). US was normal in 17 children- MRI showed a filum cyst in 1 and a lipoma in 2 children and was inconclusive in 2 children (p<0.001). All who required surgery except one child, were reported on spinal US to have a low lying cord, borderline low cord or tethered cord (p<.05). No child who was reported to have a normal spinal US required de-tethering at a later stage. Spinal US had an overall sensitivity of 91% and specificity of 75% compared to MRI for detecting spinal cord anomalies in children with ARM CONCLUSIONS: Spinal US performed in a tertiary pediatric imaging department was a good screening test for spinal cord anomalies in children with ARM. The finding of a low, borderline low or tethered cord on US mandates an MRI to confirm the findings and correlates with the need for operative correction of spinal cord tethering.

STUDY TYPE

Clinical research paper.

LEVEL OF EVIDENCE

2.

Spinal column shortening versus revision detethering for recurrent adult tethered cord syndrome: a preliminary comparison of perioperative and clinical outcomes

OBJECTIVE

Recurrent tethered cord syndrome (TCS), believed to result from tension on the distal portion of the spinal cord, causes a constellation of neurological symptoms. Detethering surgery has been the traditional treatment for TCS. However, in cases of recurrent TCS, there is a risk of new neurological deficits developing, and subsequent retethering is difficult to prevent. Spinal column shortening has been proposed as an alternative technique to reduce the tension on the spinal cord without incurring the morbidity of revision surgery on the spinal cord. The authors compared the perioperative outcomes and morbidity of patients who were treated with one or the other procedure.

METHODS

The medical records of 16 adult patients with recurrent TCS who were treated between 2005 and 2018 were reviewed. Eight patients underwent spinal column shortening, and 8 patients underwent revision detethering surgery. Patient demographics, clinical outcomes, and perioperative factors were analyzed. The authors include a video to illustrate their technique of spinal column shortening.

RESULTS

Within the spinal column shortening group, no patients experienced any complications, and all 8 patients either improved or stabilized with regard to lower-extremity and bowel and bladder function. Within the revision detethering group, 2 patients had worsening of lower-extremity strength, 3 patients had worsening of bowel and bladder function, and 1 patient had improvement in bladder function. Also, 3 patients had wound-related complications. The median estimated blood loss was 731 ml in the shortening group and 163 ml in the revision detethering group. The median operative time was 358 minutes in the shortening group and 226 minutes in the revision detethering group.

CONCLUSIONS

Clinical outcomes were comparable between the groups, but none of the spinal column shortening patients experienced worsening, whereas 3 of the revision detethering patients did and also had wound-related complications. Although the operative times and blood loss were higher in the spinal column shortening group, this procedure may be an alternative to revision detethering in extremely scarred or complex wound revision cases.

Neonatal ten-year retrospective study on neural tube defects in a second level University Hospital

BACKGROUND

Aim of this retrospective study was to describe clinical characteristics, diagnostic work-up, management and follow-up of newborns with neural tube defects (NTDs), admitted to the Mother and Child Department of the University Hospital of Palermo, in a ten years period.

METHODS

The medical records of 7 newborns (5 males and 2 females) admitted, over a 10-year period from January 2010 to March 2020, to our Department on the first day of life were reviewed. Analyzed data were related to familiar and/or maternal risk factors (consanguinity, maternal preexisting and/or gestational diseases, exposure to teratogen/infectious agents, lack of preconception folic acid supplement), demographic (ethnicity/origin, residence) and clinical features (eventual use of assisted reproduction techniques, prenatal diagnosis, gestational age, fetal presentation, type of delivery, birth weight, preoperative imaging, antibiotics and analgesics use, description of the surgery intervention, length of hospital stay, comorbidities, complications), and follow-up.

RESULTS

In our sample we observed a wide spectrum of NTDs: 3 newborns had open NTDs, namely myelomeningocele (2 lumbosacral, one of which associated with extradural lipoma, and 1 sacral), and 4 closed ones, including 2 with meningocele (occipital), 1 filar lipoma associated with dermal sinus, and 1 terminal myelocystocele. Our patients were discharged between 8 and 22 days of life. The neurodevelopmental follow-up showed a favorable outcome for 4 of the 7 patients, and the appearance over time of neurological impairment (motor and/or autonomic) in the newborns with open NTDs.

CONCLUSIONS

This study describes familiar and/or maternal risk factors and demographic and clinical features of a single-center series of newborns with NTDs. It may provide a further outline of the actual phenotypic spectrum of these malformations, and new insights into epidemiological aspects and comprehensive management of the patients, including diagnostic work-up and follow-up evaluations.

[Cutaneous signs of occult cranial and spinal dysraphism]

Dysraphism refers to neural tube closure abnormalities and midline closure abnormalities of the skin, paravertebral muscles, vertebrae and meninges. Cranial dysraphism (CD) and occult spinal dysraphism (OSD) may be discovered via evocative skin signs present at birth or appearing later in childhood or even in adulthood. This review describes the various types of skin signs associated with CD and OSD. All congenital midline skin lesions, particularly on the frontonasal area, the vertex or the occipitocervical and low back regions, should prompt suspicion of underlying dysraphism. The main evocative midline skin abnormalities are: (i) for underlying DCEO: a nodule, swelling, skin openings and hair collar sign or hair tuft; (ii) for underlying DSO, localized hypertrichosis, an atypical or complex lower back dimple, a dermoid fistula, infantile haemangioma, caudal appendage and lipoma. In the event of suspected DCEO or DSO, spinal or medullary MRI constitutes the reference examination.

Tethered cord and Chiari formation: Analysis of treatment in a relatively rare clinical situation

A 32-year-old male patient was operated for tethered cord associated with spinal lipoma. Further investigations showed the presence of basilar invagination, Chiari formation, and extensive syringomyelia. His neurological symptoms continued to worsen after the surgery, and over a 3-year period, he developed spastic quadriparesis and urinary retention and constipation. The patient was now treated by atlantoaxial fixation. Following the surgery, the patient improved in function in all four limbs and both the urinary and stool control. The presence of symptomatic Chiari formation in association with the tethered cord is a relatively rare clinical event. Surgical treatment of Chiari formation can result in a gratifying clinical recovery.

Prevalence of Abnormal Urodynamic Study Results in Patients with Congenital and Idiopathic Scoliosis and Its Predictive Value for the Diagnosis of Tethered Cord Syndrome: A Single Institution Clinical Study

Study Design

A total of 110 patients with scoliosis were enrolled in this analytical cross-sectional study.

Purpose

We aimed to compare the urodynamic study (UDS) results of patients with idiopathic scoliosis (ISC) and congenital scoliosis (CSC) and to evaluate the clinical significance of abnormal UDS findings in predicting underlying tethered cord syndrome (TCS).

Overview of Literature

An abnormal UDS finding is commonly found in patients with CSC. However, there is no consensus regarding its prevalence in patients with ISC.

Methods

Using the STROBE checklist for cross-sectional studies, 110 patients with scoliosis were selected based on our inclusion and exclusion criteria. Among the patients, 76 presented with ISC and 34 with CSC. Demographic data and other details, such as the results of spine radiography, UDS, and magnetic resonance imaging of the spine in both supine and prone positions, were recorded and analyzed.

Results

Approximately 50% of patients with CSC had normal UDS findings; 8.8%, mild impairment; and 41.2%, significant abnormalities. Moreover, 67.1% of patients with ISC had normal UDS findings; 9.2%, mild impairment; and 23.7%, significant abnormalities (p =0.166). TCS was identified in 38.2% and 26.3% of patients with CSC and ISC, respectively (p =0.571). In patients with ISC, a significantly abnormal UDS finding indicated that the risk of TCS increased from 26.3% to 50% (odds ratio [OR], 4.2; p =0.009). Meanwhile, in patients with CSC, the risk was almost similar (OR, 0.8; p =0.8).

Conclusions

Even with the absence of subjective urinary symptoms, subclinical urologic impairments can be observed in a significant number of patients with ISC. An abnormal UDS finding can be a sign of underlying spinal cord tethering in a patient with ISC who is a candidate for corrective spine surgery even though it is an independent variant and is not exclusive to candidates for surgery. This finding has high clinical utility for neuro- and ortho-spine surgeons who aim to correct scoliosis (OR, 4.2; p =0.009).

Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Meta-Analysis

OBJECTIVE

In the healthy spine, the spinal cord moves unimpeded with spinal fluid pulsation in the rostral and caudal directions. When a portion of the spinal cord becomes attached to lesions within the spinal column, excess strain can cause signs and symptoms such as pain, motor deficits, sensory deficits, bladder dysfunction, and bowel dysfunction. This condition is termed tethered cord syndrome. There are no clear guidelines for offering surgical intervention, although there is a general consensus that worsening signs and symptoms increase the likelihood that patients will need surgery.

METHODS

In this article, we conduct a systematic review and meta-analysis for all available literature within the Ovid (MEDLINE), PubMed, and Google Scholar databases to evaluate common symptoms among patients with tethered cord and to examine how surgery affects symptoms.

RESULTS

Within the cohort of 730 patients, 708 (97%) were treated surgically by a detethering procedure. The most common preoperative sign or symptom was pain (81%), followed by motor deficits (63%), sensory deficits (61%), bladder dysfunction (56%), and bowel dysfunction (15%). One percent of patients had no deficit or symptom. Pain was the symptom that was most responsive to surgery, with 81% of patients reporting that their pain improved after detethering.

CONCLUSIONS

Tethered cord syndrome should be included in the differential diagnosis in patients presenting with back or leg pain, somatosensory symptoms of the lower extremities, muscular weakness, urodynamic dysfunction, or bowel dysfunction. After a definitive diagnosis is made, patients should be counseled about surgical detethering as an option.

Towards Guideline-Based Management of Tethered Cord Syndrome in Spina Bifida: A Global Health Paradigm Shift in the Era of Prenatal Surgery

An estimated 60% of the world's population lives in Asia, where the incidence of neural tube defects is high. Aware that tethered cord syndrome (TCS) is an important comorbidity, the purpose of this systematic review was to explore the treatment of TCS among individuals living with spina bifida (SB) in Asia. MEDLINE and Embase databases were searched for relevant studies published from January 2000 to June 2018. Search terms such as 'spinal dysraphism,' 'spinabifida,' 'diastematomyelia,' 'lipomeningocele,' 'lypomyelomeningocele,' 'meningomyelocele,' and 'tethered cord syndrome' were used in diverse combinations. Of the 1,290 articles that were identified in accordance with PRISMA (Preferred Items for Systematic Reviews and Meta-Analyses) guidelines, 15 Asia-based studies met the inclusion criteria. Significant differences in the diagnostic criteria and management of TCS were documented. As the surgical techniques for prenatal closure of the spinal defect continue to evolve, their adoption internationally is likely to continue. In this setting, a clear and evidence-based approach to the definition and management of TCS is essential. The recent publication by the Spina Bifida Association of America of their updated care guidelines may serve as a tool used to promote a systematized approach to diagnosing and treating TCS among individuals with SB in the region, as well as globally.

Care management and contemporary challenges in spina bifida: a practice preference survey of the American Society of Pediatric Neurosurgeons

OBJECTIVE

Neurosurgical management preferences related to myelomeningocele (MMC) care demonstrate significant variability. The authors sought to evaluate variability in practice patterns across a group of senior pediatric neurosurgeons. The purpose of this study was to identify the extent of variability and of consensus with regard to neurosurgical management of MMC and associated hydrocephalus, Chiari II malformation, and tethered spinal cord.

METHODS

A 43-question survey was distributed electronically to the members of the American Society of Pediatric Neurosurgeons (ASPN). The survey covered domains such as clinic case volume, newborn management, hydrocephalus management, transition to adulthood, clinical indications for shunt revision, Chiari II malformation decompression (C2MD), and tethered cord release (TCR). Ninety responses were received from 200 active ASPN members, for an overall response rate of 45%.

RESULTS

The majority (58%) of respondents closed 5-15 new cases of open MMC per year. Nearly all (98%) respondents perform back closure within 48 hours of birth, with the majority imbricating the placode and striving for a 3- to 4-layer closure. The most consistent indications for surgical intervention in early hydrocephalus were CSF leak from the back (92%), progressive ventricular enlargement (89%), and brainstem symptoms, including apnea/bradycardia (81%), stridor (81%), and dysphagia (81%). Eighty percent of respondents indicated that spina bifida care is delivered through multidisciplinary clinics, with neurosurgery, orthopedic surgery, urology, physical therapy, and social work as the most common disciplines included. One-third of clinics see both pediatric and adult patients, one-third offer a formal transition program to adult care, and one-third have no transition program. The vast majority of respondents offer prenatal counseling (95%), referral for in utero closure (66%), and endoscopic third ventriculostomy/choroid plexus cauterization (72%). Respondents were more willing to perform shunt revision for symptoms alone than for image changes alone. An asymptomatic broken shunt without ventricular enlargement produced responses evenly divided between observation, intervention, and further investigation. Operative shunt exploration was always performed before C2MD by 56% of respondents and performed sometimes by 40% of respondents. Symptoms of brainstem dysfunction were the strongest clinical triggers reported for C2MD, while declines in urinary continence, leg strength or sensation, or ambulation were the most consistent thresholds for TCR.

CONCLUSIONS

Significant disparities exist surrounding key areas of decision making regarding treatment for patients with MMC, though there are central areas of agreement among ASPN members. Additionally, there is significant variation in the clinical management of chronic hydrocephalus, C2MD, and TCR, underscoring the need for further research into these specific areas.

The Use of Prone Magnetic Resonance Imaging to Rule Out Tethered Cord in Patients With Structural Spine Anomalies: A Diagnostic Technical Note for Surgical Decision-making

Tethered cord syndrome (TCS) is a clinical diagnosis that can be difficult to establish, as symptoms do not always match classic radiological findings, such as a low-lying conus. Surgery for spinal detethering is not without risk and does not always result in clinical improvement. Prone magnetic resonance imaging (MRI) has been described as a tool to assess the mobility of the spine. This is a technical imaging report where prone imaging was a factor that influenced the decision to defer surgery in favor of conservative management. T1 and T2 sagittal and T1 axial MRI imaging were obtained with the patient supine, and then repeated in the prone position. An anteroposterior conus movement of >10% of the canal width was considered normal. There was significant anterior movement of the conus when switching to the prone position. Surgery was deferred, and the patient improved after a regimen of intensive physical therapy. Prone MRI can be a useful tool to have in our neurosurgical armamentarium when assessing spinal cord tethering. Surgery is not recommended when normal anteroposterior movement of the conus is present.

Morphometric analysis of spinal cord termination in Cavalier King Charles Spaniels

BACKGROUND

There is an association between Chiari malformations, syringomyelia (CMSM) and tethered cord syndrome (TCS) in people, suggesting Cavalier King Charles Spaniels (CKCS) with CMSM could also have TCS. Currently there are no data on the position of the caudal spinal cord structures in CKCS.

OBJECTIVE

To describe and compare location of spinal cord termination in CKCS with weight-matched controls and to examine the relationship between SM and spinal cord termination.

ANIMALS

Thirty-nine CKCS and 33 controls with thoracolumbar MRIs; 34 of 39 CKCS also had cervical MRIs.

METHODS

Blinded retrospective study. Spinal cord and dural sac termination were determined from T2-weighted sagittal and transverse images and half-Fourier acquisition single-shot turbo spin echo sequences. Intra-observer reliability was determined using kappa analysis. Presence of SM was compared with location of spinal cord and dural sac termination.

RESULTS

Intra-observer reliability was moderate for identifying spinal cord termination (Kappa = 0.6) and good for dural sac termination (Kappa = 0.8). The spinal cord terminated at lumbar vertebra 6 (L6) in 1, 7 (L7) in 22, and sacrum in 16 CKCS versus 9 at L6, 23 at L7, 1 at sacrum in controls. Spinal cord (P < .001) and dural sac (P = .002) termination were significantly more caudal in CKCS compared to controls. The presence of thoracolumbar SM was associated with more caudal dural sac termination in CKCS (P = .03).

CONCLUSIONS AND CLINICAL IMPORTANCE

The relationship between TL SM and possible spinal cord tethering because of a more caudal dural sac termination should be investigated.

TRIM4 is associated with neural tube defects based on genome-wide DNA methylation analysis

BACKGROUND

Neural tube defects (NTDs) are complex abnormalities associated with gene-environment interactions. The underlying cause has not been determined.

METHODS

Spinal cord tissues from cases with NTDs and healthy controls were collected. Methylation patterns between cases and normal individuals were compared using 450K Infinium Methylation BeadChip Illumina. DNA methylation analysis by pyrosequencing (PyroMark Q96) and mRNA and protein expression were analyzed using real-time quantitative PCR and Western blotting, respectively. Next-generation and Sanger sequencing were used to determine genetic variants in the target genes.

RESULTS

Spinal cord tissues from cases with NTDs had more hypomethylated than hypermethylated genes. Further evaluation showed that the exon 1 region of TRIM4 was hypomethylated, and TRIM4 mRNA and protein levels were significantly increased in NTDs compared to controls. A rare missense variant (rs76665876) in TRIM4 was found in 3 of the 14 NTD cases but was not related to TRIM4 expression. TRIM4 mRNA levels were significantly increased in cases with hypomethylation and without the rs76665876 variant.

CONCLUSION

These findings suggest that spinal cord tissues in cases with NTDs had a different genome-wide methylation pattern compared to controls. Abnormal methylation patterns in TRIM4 in immunity pathways might be involved in NTD pathogenesis. Genetic variants in TRIM4 genes only slightly contribute to the etiology of human NTDs.

Expression profiles of pro-inflammatory and pro-apoptotic mediators in secondary tethered cord syndrome after myelomeningocele repair surgery

PURPOSE

The literature on histopathological and molecular changes that might underlie secondary tethered cord syndrome (TCS) after myelomeningocele (MMC) repair surgeries remains sparse. To address this problem, we analyzed specimens, which were obtained during untethering surgeries of patients who had a history of MMC repair surgery after birth.

METHODS

Specimens of 12 patients were analyzed in this study. Clinical characteristics were obtained retrospectively including pre-operative neurological and bowel/bladder-function, contractures and spasticity of lower extremities, leg and back pain, syringomyelia, and conus position on spinal MRI. Cellular marker expression profiles were established. Further, immunoreactivities (IR) of IL-1ß/IL-1R1, TNF-α/TNF-R1, and HIF-1α/-2α were analyzed qualitatively and semi-quantitatively by densitometry. Co-labeling with cellular markers was determined by multi-fluorescence-labeling. Cytokines were further analyzed on mRNA level. Immunostaining for cleaved PARP and TUNEL was performed to detect apoptotic cells.

RESULTS

Astrocytosis, appearance of monocytes, activated microglia, and apoptotic cells in TCS specimens were one substantial finding of these studies. Besides neurons, these cells co-stained with IL-1ß and TNF-α and their receptors, which were found on significantly elevated IR-level and partially mRNA-level in TCS specimens. Staining for HIF-1α/-2α confirmed induction of hypoxia-related factors in TCS specimens that were co-labeled with IL-1ß. Further, hints for apoptotic cell death became evident by TUNEL and PARP-positive cells in TCS neuroepithelia.

CONCLUSIONS

Our studies identified pro-inflammatory and pro-apoptotic mediators that, besides mechanical damaging and along with hypoxia, might promote TCS development. Besides optimizing surgical techniques, these factors should also be taken into account when searching for further options to improve TCS treatment.

Tethered cord in children with anorectal malformations with emphasis on rectobladder neck fistula

PURPOSE

To find the incidence of tethered cord (TC) in patients with anorectal malformations (ARM) and to determine the relationship between bowel/urinary control and TC in a subset of patients with rectobladder neck fistula (RBNF).

METHODS

The database of a tertiary medical center was retrospectively collected for all patients treated for ARM from 1980 to 2012. All patients with TC and RBNF were identified.

RESULTS

Among 790 patients, who underwent screening for TC, 285(36%) were diagnosed with TC. Eleven of 37 screened patients with RBNF were diagnosed with TC. The median follow-up period was 49 months (range 2-222 months). TC was diagnosed in 3/18(16.6%) patients with sacral ratio (SR) ≥ 0.7; 4/12(33.3%) with SR 0.41-0.69; and 4/7(57.1%) patients with SR 0-0.4. The association of TC in RBNF patients had a negative influence in the prognosis for bowel and urinary control.

CONCLUSION

The incidence of TC among patients with ARM is 36%. Incidence of TC among patients with RBNF correlates with SR value and is higher with lower SR. Patients with RBNF and TC have dismal prognosis for bowel control, unrelated to their SR status. Many unresolved questions related to the management of ARM patients with asymptomatic TC still remain.

Microsurgical efficacy in 326 children with tethered cord syndrome: a retrospective analysis

Tethered cord syndrome is a progressive disease with a typically insidious onset in infants and children, and which can lead to persistent progress of neurological deficits and a high rate of disability without timely intervention. The purpose of this study was to investigate the curative effect of microsurgery in children with different types of tethered cord syndrome. In this study, we analyzed 326 patients with tethered cord syndrome, aged from 2 months to 14 years old, who were followed for 3-36 months after microscopic surgery. Based on clinical manifestations and imaging findings, these patients were classified into five types: tight filum terminale (53 cases), lipomyelomeningocele (55 cases), lipomatous malformation (124 cases), postoperative adhesions (56 cases), and split cord malformation (38 cases). All patients underwent microsurgery. Curative effects were measured before and 3 months after surgery by Spina Bifida Neurological Scale based on sensory and motor functions, reflexes, and bladder and bowel function. The results showed that Spina Bifida Neurological Scale scores improved in all five types after surgery. Overall effective rates in these patients were 75%. Effective rates were 91% in tight filum terminale, 84% in lipomyelomeningocele, 65% in lipomatous malformation, 75% in postoperative adhesion, and 79% in split cord malformation. Binary logistic regression analysis revealed that types of tethered cord syndrome (lipoma-type or not) and symptom duration before surgery were independent influencing factors of surgical outcome. These results show that therapeutic effect is markedly different in patients with different types of tethered cord syndrome. Suitable clinical classification for tethered cord syndrome will be helpful in predicting prognosis and guiding treatment. This trial has been registered in the Chinese Clinical Trial Registry (registration number: ChiCTR1800016464).

Can sacral development as a marker for caudal regression help identify associated urologic anomalies in patients with anorectal malformation?

BACKGROUND AND AIM

The sacral ratio (SR) is a well-established tool to quantify sacral development in patients with anorectal malformations (ARM) and can be used as a predictor of fecal continence. We hypothesized that a lower SR correlated with the presence of urologic and renal malformations.

METHODS

We retrospectively reviewed the medical records of patients with ARM treated at our center from 2014 to 2016. We measured the lateral SR as a marker for sacral development and assessed the spine for the presence of tethered cord (TC). Urological and renal anomalies, including single kidney, hydronephrosis, hypospadias, vesicoureteral reflux (VUR), ectopic ureter, and penoscrotal transposition were assessed. Analysis of variance (ANOVA), t-tests, and multivariable linear regression were used to test for differences in SR with consideration of associated urologic malformations and tethered cord.

RESULTS

283 patients with ARM were included for analysis (156 females). The median age was 39months (10-90). Among these, 178 (55.6%) had 1 or more urologic malformations, and 81 (25.3%) had a TC. Hydronephrosis, high-grade VUR (3-5), solitary kidney, and tethered cord were significantly associated with lower SR (p<0.01). In multivariable regression models, the presence of urologic abnormalities remained significantly associated with lower a SR despite the presence or absence of TC (p<0.001).

CONCLUSION

SR is a potentially useful indicator of certain urologic anomalies including hydronephrosis, high grade VUR, and solitary kidney in patients with ARM. This association is independent of the presence of TC. A sacral ratio as a part of the VACTERL screening can help the surgeon identify which patients need closer urologic follow up.

LEVEL OF EVIDENCE

IV.

Predictive value of intraoperative bulbocavernosus reflex during untethering surgery for post-operative voiding function

OBJECTIVE

To evaluate the clinical significance of intraoperative bulbocavernosus reflex (BCR) during untethering surgery in predicting post-operative voiding function.

METHODS

We conducted a retrospective review of pediatric patients who underwent untethering surgery with available intraoperative baseline BCR. BCR response during surgery was classified into loss or maintenance. Post-operative voiding function was determined as worsened or maintained based on history, postvoid residual urine measurement, and urodynamic study (UDS). Data regarding demographics, diagnosis, pre-operative voiding difficulty, re-untethering, syrinx, and abnormalities in electromyography were collected for analysis.

RESULTS

We included 106 patients, with a mean age of 3.3 years, and 49 patients were male. BCR was lost in 15 patients during surgery and voiding function worsened in 14 patients after surgery. Lumbosacral lipoma was the most common diagnosis, and 16 patients were diagnosed with lipomyelomeningocele (LMMC). The sensitivity and specificity of intraoperative BCR for post-operative worsening of voiding function were 35.7%, and 88.5% at 6 months, respectively. The diagnosis of LMMC was statistically significant in a logistic regression analysis. The specificity of BCR at 6 months in patients with diagnosis other than LMMC was 93.4%, and intraoperative BCR was significant in a logistic regression analysis.

CONCLUSIONS

Intraoperative BCR during untethering could predict bladder function 6 months post-operatively with high specificity (88.5%), particularly in cases other than LMMC (93.4%), indicating that voiding function deterioration will not occur if intraoperative BCR is preserved.

SIGNIFICANCE

Intraoperative BCR during untethering surgery is a useful tool to predict post-operative voiding outcome.

Intraspinal Anomalies in Early Onset Scoliosis: Current Concepts

Early onset scoliosis (EOS) is deformity of the spine below the age of 5 years. Children with EOS are at risk of impaired thoracic cage development and pulmonary maturation. Initial evaluation consists of determining the etiological cause for EOS, i.e., congenital, neurogenic, idiopathic, or syndromic. The advent of magnetic resonance imaging in recent times has lead to increased awareness of neurogenic causes leading to EOS. Evaluation of spinal cord anomalies in EOS is very important as early diagnosis and treatment can help in deformity stabilization and regression. Also, any surgical or nonsurgical intervention to correct the deformity without prior treatment of spinal cord anomalies can lead to disastrous neurological complications.

Outcome of ultrasonographic imaging in infants with sacral dimple

Purpose

Sacral dimples are a common cutaneous anomaly in infants. Spine ultrasonography (USG) is an effective and safe screening tool for patients with a sacral dimple. The aim of this study was to determine the clinical manifestations in patients with an isolated sacral dimple and to review the management of spinal cord abnormalities identified with USG.

Methods

We reviewed clinical records and collected data on admissions for a sacral dimple from March 2014 through February 2017 that were evaluated with spine USG by a pediatric radiologist. During the same period, patients who were admitted for other complaints, but were found to have a sacral dimple were also included.

Results

This study included 230 infants under 6-months-old (130 males and 100 females; mean age 52.8±42.6 days). Thirty-one infants with a sacral dimple had an echogenic filum terminale, and 57 children had a filar cyst. Twenty-seven patients had a low-lying spinal cord, and only one patient was suspected of having a tethered cord. Follow-up spine USG was performed in 28 patients, which showed normalization or insignificant change.

Conclusion

In this study, all but one infant with a sacral dimple had benign imaging findings. USG can be recommended in infants with a sacral dimple for its convenience and safety.

Clinical Outcomes of Primary and Revision Untethering Surgery in Patients with Tethered Cord Syndrome and Spinal Bifida

BACKGROUND

Tethered cord syndrome (TCS) is an increasingly recognized clinical condition, with untethering surgery considered the classically effective treatment. Yet, as evidence has aggregated, the surgical outcomes of untethering remain controversial. This study aimed to systematically evaluate the clinical outcomes in patients who underwent primary or revision untethering.

METHODS

This retrospective study was conducted at the Department of Spine Surgery of Changzheng Hospital between January and December 2016. Patients with TCS who underwent untethering surgery were recruited for the study. Information collected included demographic data, main clinical manifestations, and outcomes after untethering surgery.

RESULTS

A total of 112 patients (60 males and 52 females) were included in this study, with mean follow-up of 13.7 years. The surgical outcomes of the primary untethering varied among symptoms, with remission rates of 30.0% for pain, 24.4% for paresthesia, 18.6% for motor deficit, 12.6% for bladder dysfunction, and 21.2% for bowel dysfunction. Moreover, 23.3%-40.2% of patients suffered deterioration after surgery during the follow-up period. Twenty-eight patients underwent revision untethering surgery. In these patients, the remission rate decreased by 5.6%-16.7% compared with the primary operation. Moreover, most patients (58.8%-70.6%) experienced no benefits after revision surgery.

CONCLUSIONS

With a possible high risk of recurrence, further exploration of the indications and timing of the untethering surgery is needed. Conservative treatment and omnidirectional care might be a better choice for patients with retethering with recurrent symptoms.

Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child: A case report and literature review

RATIONALE

Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder.

PATIENT CONCERNS

A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis.

INTERVENTIONS

He was operated on successfully and the cervical lordosis and pain resolved.

OUTCOMES

The child recovered well with no tumor recurrence and massive improvement of his life.

LESSONS

The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.

Response of Scoliosis in Children with Myelomeningocele to Surgical Release of Tethered Spinal Cord

Objective: To examine the effect of surgical tethered cord release (TCR) on scoliosis in children with myelomeningocele. Methods: A retrospective review of 65 pediatric patients with myelomeningocele and TCR. The final sample consisted of 20 patients with scoliosis who were managed conservatively after TCR. Results: Average age at TCR was 6.2 years with average follow-up of 3.8 years. Scoliosis of 1 (5%) patient improved, 7 (35%) were stable, and 12 (60%) worsened (≥10°). Fifty percent of patients ultimately required definitive spinal surgery. TCR release delayed definitive spine surgery for an average of 3.2 years. Sixty-four percent of patients with curves less than or equal to 45° had progression of their curves compared to 50% with curves greater than 45°. For patients with curves less than or equal to 45°, curves progressed in 80% of those younger than 10 years as compared to 25% of those older than 10 years. For patients with curves less than or equal to 45°, 43% required definitive spine surgery as opposed to 83% with curves greater than 45°. Level of neurological involvement (ie, lumbar versus thoracic) and age at untethering emerged as factors influencing the effects of TCR for patients with curves less than or equal to 45°. Lumbar curves had more favorable results. Conclusion: Pediatric patients with myelomeningocele and scoliosis should be closely assessed and monitored. A selective approach for youth with lumbosacral level myelomeningocele and progressive curves less than or equal to 45° may result in scoliosis stabilization and avoidance of definitive surgery.

Tethered Cord as a Complication of Chronic Cerebral Spinal Fluid Diversion

Introduction

The etiology and treatment of tethered cord syndrome remains controversial, especially in adults. We present an unusual case of tethered cord syndrome with an associated epidural lipomatosis likely due to chronic over shunting of cerebrospinal fluid (CSF).

Methods

A 25-year-old woman had a history of Chiari malformation, hydrocephalus, and a ventriculoperitoneal shunt. She demonstrated progressively worsening gait, which led to a diagnosis of myelopathy and a posterior cervical decompression and fusion was performed. Imaging revealed engorgement of the epidural veins ventral to the spinal cord which was causing cord compression. Magnetic resonance (MR) imaging of the lumbar spine demonstrated a low-lying conus at the level of L2-L3 with an absence of CSF in the lumbar cistern. This was associated with this was a widening of the epidural space with secondary epidural lipomatosis. She underwent a laminectomy of L5 as well as decompression of the inferior aspect of the L4 and superior aspect of the S1 lamina. No free flow of CSF could ever be appreciated as was suggested by postoperative MR imaging. Postoperatively, the patient did well and was discharged in stable condition.

Conclusion

Tethering of the spinal cord, associated with epidural lipomatosis, may be secondary to over-drainage of CSF. Symptoms of back pain and tethered cord phenomenon may warrant surgical intervention.

Magnetic resonance imaging in the prone position and the diagnosis of tethered spinal cord

OBJECTIVE Tethered cord syndrome (TCS) is a neurosurgical disorder with varied clinical manifestations believed to result from vascular compromise due to stretch forces on the spinal cord. Conventional supine MRI findings may include a low-lying conus medullaris, thickened or fat-infiltrated filum terminale, or lipoma; however, imaging sensitivity and specificity for tethered cord can be low. The purpose of this study was to evaluate the utility of prone MRI in the diagnosis of tethered and retethered spinal cord. METHODS Medical records were reviewed in 41 patients who underwent surgical release of tethered cord and in whom preoperative prone MRI sequences were available. Patients were divided into Group 1 (new TCS diagnosis) and Group 2 (recurrent TCS after previous untethering). Absolute conus ventral motion and motion as a percentage of canal width between supine and prone positions was measured in these 2 groups via sagittal T2-weighted sequences; these groups were compared with 30 consecutive patients (Group 3) who were classified as the normal control group. RESULTS The mean ventral motion was as follows: Group 1 (absolute: 0.5 ± 0.5 mm [range 0-2.4 mm]; canal percentage: 3.7% ± 3.9% [range 0%-16.3%]); Group 2 (absolute: 0.4 ± 0.7 mm [range 0-2.6 mm]; canal percentage: 2.2% ± 3.7% [range 0%-14.0%]); and Group 3 (absolute: 3.4 ± 1.3 mm [range 1.4-5.6 mm]; canal percentage: 22.0% ± 7.2% [range 10.5%-36.1%]). Whereas 38/41 surgically treated patients with TCS had diminished (< 10% canal width) ventral motion on preoperative MRI, 30/30 controls had > 10% canal width motion. Sensitivity and specificity were thereby calculated as 92.7% and 100%, respectively. CONCLUSIONS In the present series, prone imaging is found to be a sensitive and specific tool, and the authors believe it may have a role as supportive evidence in the diagnosis of tethered and retethered spinal cord.

Evaluation of Dorsal Midline Discolorations with Physical Examination and Ultrasound

OBJECTIVE

To assess the association between dorsal midline skin discolorations, tethering of the spinal cord, and the role of ultrasound screening of these stigmata, focusing specifically on vascular lesions.

STUDY DESIGN

We conducted a prospective observational study of infants <6 months of age with suspicious dorsal midline skin stigmata. All were evaluated by physical examination and ultrasound scan. A subset also had a magnetic resonance imaging examination. We examined the association between small, red-shaded discolorations and their respective imaging findings.

RESULTS

Among 100 cases with discolorations of vascular types, either isolated or combined with low-risk simple dimples or deviated gluteal folds, none had clinically significant pathologic findings requiring surgical intervention.

CONCLUSIONS

Midline lumbar discolorations are more benign than previously thought. Despite the very low association of this group of stigmata with surgical implications, we still recommend the routine use of ultrasound scanning.

Optimal stimulation parameters for intraoperative bulbocavernosus reflex in infants

OBJECTIVE The aim of this study was to establish optimal electric stimulation parameters for intraoperatively monitoring the bulbocavernosus reflexes (BCRs) in infants. METHODS The authors retrospectively reviewed the medical records of all infants (age < 24 months) who had undergone an untethering operation for tethered cord syndrome between May 2013 and February 2014 at a single institution and whose baseline BCR had been elicited during surgery. Using different combinations of stimulation parameters-number of stimulation pulses: 4 or 8 pulses, interpulse interval: 1, 2, or 5 msec, and polarity of stimulation: biphasic or monophasic-the authors compared the relative mean amplitude of 10 BCR responses (rmaBCRs) to each combination of parameters. RESULTS The rmaBCRs were larger with the 8-pulse stimulations than with the 4-pulse stimulations (p < 0.0001). There was a tendency, though not statistically significant, for larger rmaBCRs to be obtained with the longer interpulse interval in the 8-pulse stimulation (p = 0.1289). The biphasic stimulation produced larger rmaBCRs than the monophasic stimulation (p = 0.0005). CONCLUSIONS Biphasic 8-pulse stimulations with 5-msec or 2-msec intervals yield the largest BCR responses. Considering that an 8-pulse stimulation with 5-msec intervals may overlap the onset of the BCR, a biphasic 8-pulse stimulation with 2-msec intervals is recommended as the optimal stimulation paradigm to monitor intraoperative BCRs in infants.

Management of concomitant scoliosis and tethered cord syndrome in non-spina bifida pediatric population

BACKGROUND

The management of concomitant scoliosis and tethered cord syndrome in the non-spina bifida pediatric population is challenging. In the present study, we evaluate the efficacy of different treatment modalities and propose a treatment plan for the management of affected patients.

METHODS

A systematic literature review was conducted by querying the MEDLINE, PubMed, Cochrane, EMBASE, Scopus, and Web of Science databases for papers published between January 1996 and June 2016 and reporting on concomitant scoliosis and tethered cord. We excluded animal studies, non-English papers as well as papers reporting on patients with multiple concomitant intraspinal anomalies such as spina bifida.

RESULTS

Out of 1993 articles, only 13 met our inclusion criteria. These 13 articles described six main management approaches: Observation, cord untethering only, cord untethering followed by deformity correction, simultaneous cord untethering and deformity correction, and deformity correction without untethering. Selection of the best approach is a function of the patient's symptomatology and Cobb angle.

CONCLUSION

We propose treatment plan for the management of patients with concomitant tethered cord syndrome and spinal deformity. Asymptomatic patients can be followed conservatively and managed as scoliosis patients with no need for untethering. Surgical management in a staged fashion seems appropriate in symptomatic patients with a Cobb angle less than 35°. In these patients, deformity can improve following untethering, thus sparing the patient the risks of surgical correction of scoliosis. Staged or non-staged cord untethering and curve correction seem to be adequate in symptomatic patients with Cobb angle >35° as these patients are likely to require both untethering and deformity correction.

A parental perspective concerning barriers to care for neural tube defects in China

Background:

The People's Republic of China (PRC) has the highest incidence of neural tube defects (NTDs) in the world. NTDs remain a significant contributor to the global burden of disease amendable to surgical care; however, no studies to date have evaluated the patients’ perspective regarding perceived barriers to care.

Methods:

The study was conducted at the Shanghai Children's Medical Center (SCMC) between 6/11/2014 and 7/17/2014. Surveys were administered to families presenting to the clinic of the SCMC director for Pediatric Neurosurgery. Additionally, orphaned patients under the care of the Baobei Foundation were surveyed for comparison. Participants were allowed to mark as many barriers on the survey as they deemed relevant to their experience.

Results:

A total of 69 patients were surveyed. The most frequently chosen barrier to care, with a P value < 10^-5, was that the referring physician did not know enough about the child's condition. As compared to the Baobei Foundation orphans, surveyed patients presented at an older age for initial treatment (7 months versus 1 month, P value = 0.001), and visited more hospitals before reaching SCMC (3.14 versus 1.0, P value < 10^-5).

Conclusions:

The results of this study highlight the referring physician as a primary barrier to care. The younger age at time of treatment for Baobei orphans born with NTDs supports this finding, as they essentially bypassed the referral process. An elaboration on reasons for this real or perceived barrier may provide insight into a means for expedited diagnosis and treatment of NTDs within the PRC.

Dynamic Lumbosacral Magnetic Resonance Imaging in a Dog with Tethered Cord Syndrome with a Tight Filum Terminale

A 1-year and 11-month- old English Cocker Spaniel was evaluated for clinical signs of progressive right pelvic limb lameness and urinary incontinence. Neurological examination was suggestive of a lesion localized to the L4–S3 spinal cord segments. No abnormalities were seen on magnetic resonance imaging (MRI) performed in the dog in dorsal recumbency and the hips in a neutral position and the conus medullaris ended halfway the vertebral body of L7. An MRI of the hips in extended and flexed positions demonstrated minimal displacement of the conus medullaris in the cranial and caudal directions, respectively. Similar to the images in neutral position, the conus medullaris ended halfway the vertebral body of L7 in both the extended and flexed positions. In comparison, an MRI of the hips in neutral, extended, and flexed positions performed in another English Cocker Spaniel revealed obvious cranial displacement of the conus medullaris with the hips in extension and caudal displacement with hips in flexion. A standard dorsal lumbosacral laminectomy was performed. Visual inspection of the vertebral canal revealed excessive caudal traction on the conus medullaris. After sectioning the distal aspect of the filum terminale, the conus medullaris regained a more cranial position. A neurological examination 4 weeks after surgery revealed clinical improvement. Neurological examinations at 2, 4, 7, and 12 months after surgery did not reveal any abnormalities, and the dog was considered to be clinically normal. Tethered cord syndrome with a tight filum terminale is a very rare congenital anomaly and is characterized by an abnormally short and inelastic filum terminale. Therefore, this disorder is associated with abnormal caudal traction on the spinal cord and decreased physiological craniocaudal movements of the neural structures within the vertebral canal. Although further studies are necessary to evaluate and quantify physiological craniocaudal movement of the spinal cord and conus medullaris in neurologically normal dogs, the results of this report suggest further exploration of dynamic MRI to demonstrate decreased craniocaudal displacement of the conus medullaris in dogs with tethered cord syndrome with a tight filum terminale.

Mini-open spinal column shortening for the treatment of adult tethered cord syndrome

Tethered cord syndrome (TCS) is a challenging entity characterized by adhesions at the caudal spinal cord that prevent upward movement during growth and result in stretching of the cord with a concomitant constellation of neurologic symptoms. Although growth in height stops in adulthood, some patients still develop progressive symptoms; many underwent detethering as a child or adolescent, resulting in significant scar tissue and re-tethering. Recent strategies have focused on spinal column shortening to reduce tension on the spinal cord without exposing the previous de-tethering site. Mini-open and minimally invasive approaches avoid the large dissection and exposure associated with traditional approaches and are associated with reduced blood loss, shorter hospital stay, and similar outcomes when compared to conventional open approaches. We describe a technique for mini-open spinal column shortening. Using intraoperative navigation pedicle screws were placed at T10, T11, L1, and L2. A mini-open 3-column "egg shell" decancellation osteotomy of T12 was performed through a transpedicular approach with preservation of the superior and inferior endplates. This procedure was performed on a 28year old male with recurrent TCS and neurogenic bladder. Postoperative imaging showed a reduction in spinal column length of 1.5cm and evidence of decreased tension on the spinal cord. At last follow-up he was recovering well with improved urinary function. Spinal column shortening for adult TCS can be safely achieved through a mini-open approach. Future studies should compare the efficacy of this technique to both traditional de-tethering and open spinal column shortening.

Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society

AIMS

As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Children's Continence Society (ICCS) recommendations for diagnosis and treatment of OSD.

METHODS

Guidelines were formulated based on analysis of pertinent literature and consensus among authors. This document was vetted by the multidisciplinary members of the ICCS via its website before submission for peer review publication.

RESULTS

The more frequent diagnosis of OSD is associated with increased operative intervention. Spinal cord untethering (SCU) has a highly variable risk profile, largely dependent on the specific form of OSD. Progressive neurological deterioration attributed to "tethered cord" may occur, with or without surgery, in selected forms of OSD whereas other cohorts do well.

CONCLUSION

Infants with classic cutaneous markers of OSD, with progressive neurologic, skeletal, and/or urologic findings, present no diagnostic or therapeutic dilemma: they routinely undergo MRI and SCU. Conversely, in asymptomatic patients or those with fixed, minor abnormalities, the risk profile of these OSD cohorts should be carefully considered before SCU is performed. Irrespective of whether or not SCU is performed, patients at risk for progression should be followed carefully throughout childhood and adolescence by a multidisciplinary team.

Tethered cord in patients affected by anorectal malformations: a survey from the ARM-Net Consortium

PURPOSE

The goal of this study was to determine the degree of consensus in the management of spinal cord tethering (TC) in patients with anorectal malformation (ARM) in a large cohort of European pediatric centers.

METHODS

A survey was sent to pediatric surgeons (one per center) members of the ARM-Net Consortium.

RESULTS

Twenty-four (86%) from ten different countries completed the survey. Overall prevalence of TC was: 21% unknown, 46% below 15, and 29% between 15 and 30%. Ninety-six agreed on screening all patients for TC regardless the type of ARM and 79% start screening at birth. Responses varied in TC definition and diagnostic tools. Fifty percent of respondents prefer ultrasound (US), 21% indicate either US or magnetic resonance (MRI) based on a pre-defined risk of presenting TC, and 21% perform both. Discrepancy exists in complementary test: 82% carry out urodynamic studies (UDS) and only 37% perform somatosensory-evoked potentials (SSEP). Prophylactic untethering is performed in only two centers (8%).

CONCLUSIONS

Survey results support TC screening in all patients with ARM and conservative management of TC. There is discrepancy in the definition of TC, screening tools, and complementary test. Protocols should be developed to avoid such variability in management.

More preoperative flexibility implies adequate neural pliability for curve correction without prophylactic untethering in scoliosis patients with asymptomatic tethered spinal cord, a retrospective study

Background

Tethered spinal cord is frequently associated with scoliosis. It is still controversial whether a prophylactic untethering is necessary before correction procedure in scoliosis patients with tethered spinal cord. In this study we determined the clinical outcome of a one-stage posterior scoliosis correction without a prophylactic untethering for treating scoliosis with an asymptomatic tethered spinal cord.

Methods

Seventeen (5 males and 12 females) scoliosis patients with tethered spinal cords were retrospectively reviewed. All patients underwent a one-stage posterior scoliosis correction without preventive untethering. Parameters of radiograph were used to assess correction result. The Scoliosis Research Society (SRS)-22 questionnaire was analyzed pre- and post-operatively to evaluate the clinical outcomes. The modified Japanese Orthopaedic Association (mJOA) score was used to assess the pre- and post-operative spinal cord function.

Results

The post-operative coronal Cobb angle was significantly decreased compared with preoperative. (23.8 ± 6.4° vs. 58.4 ± 12.6°, P < 0.01). The coronal Cobb angle was 22.4 ± 6.8° at the final follow-up evaluation. The apical vertebral translation (AVT) was also decreased significantly. (27.5 mm vs. 60.9 mm, P < 0.01). The SRS-22 total score was improved at the 1-year follow-up evaluation compared with the pre-operative SRS-22 total score (87 ± 4 vs. 70 ± 5, p < 0.05). The functional activities, pain, self-image, mental health, and surgery satisfactory scores at the final follow-up evaluation were all improved compared with the corresponding pre-operative scores, especially the self-image and mental health scores (p < 0.05). The spinal cord function was stable and there was no new neurological symptoms after scoliosis correction. No difference existed between the pre- and post-operative total mJOA score (26 ± 2 vs. 27 ± 2, p = 0.39), which including subjective symptom (p = 0.07), clinical symptom (p = 0.33), daily activities (p = 0.44) and bladder function (p = 0.67).

Conclusion

One-stage posterior scoliosis correction is a safe and effective surgical procedure for scoliosis patients combined with asymptomatic tethered spinal cord who have adequate spinal cord function reserve.

Trends in the presentation, surgical treatment, and outcomes of tethered cord syndrome: A nationwide study from 2001 to 2010

OBJECTIVE

This is a nationwide query into surgical management techniques for tethered cord syndrome, focusing on patient demographic, hospital characteristics, and treatment outcomes. Our hypothesis is that detethering vs. fusion for TCS results in different in-hospital complications.

MATERIALS AND METHODS

Retrospective review of the Nationwide Inpatient Sample 2001-2010. Inclusion: TCS discharges undergoing detethering or fusion. Sub-analysis compared TCS cases by age (pediatric [≤9years] vs. adolescent [10-18year]). Independent t-tests identified differences between fusion and detethering for hospital-related and surgical factors; multivariate analysis investigated procedure as a risk factor for complications/mortality.

RESULTS

6457 TCS discharges: 5844 detetherings, 613 fusions. Fusion TCS had higher baseline Deyo Index (0.16 vs. 0.06), procedure-related complications (21.3% vs. 7.63%), and mortality (0.33% vs. 0.09%) than detethering, all p<0.001. Detethering for TCS was a significant factor for reducing mortality (OR 0.195, p<0.001), cardiac (OR 0.27, p<0.001), respiratory (OR 0.26, p<0.001), digestive system (OR 0.32, p<0.001), puncture nerve/vessel (OR 0.56, p=0.009), wound (OR 0.25, p<0.001), infection (OR 0.29, p<0.001), posthemorrhagic anemia (OR 0.04, p=0.002), ARDS (OR 0.13, p<0.001), and venous thrombotic (OR 0.53, p=0.043) complications. Detethering increased nervous system (OR 1.34, p=0.049) and urinary (OR 2.60, p<0.001) complications. Adolescent TCS had higher Deyo score (0.08 vs. 0.03, p<0.001), LOS (5.77 vs. 4.13days, p<0.001), and charges ($54,592.28 vs. $33,043.83, p<0.001), but similar mortality. Adolescent TCS discharges had increased prevalence of all procedure-related complications, and higher overall complication rate (11.10% vs. 5.08%, p<0.001) than pediatric.

CONCLUSIONS

With fusion identified as a significant risk factor for mortality and multiple procedure-related complications in TCS surgical patients, this study could aid surgeons in counseling TCS patients to optimize outcomes.

Long-term evaluation of intraoperative neurophysiological monitoring-assisted tethered cord surgery

PURPOSE

Patients with tethered spinal cord have been investigated for short-term effects after tethered spinal cord surgery in the past. However, little is known about the long-term effects in this patient group. In this retrospective, longitudinal, observational study, a patient sample of a previous report of 65 patients was reassessed to observe the long-term effects of intraoperative neurophysiological monitoring-assisted tethered cord surgery.

METHODS

With the use of patient charts and a survey, patients were scored on four domains: (1) neurological deficits, (2) urological deficits, (3) pain symptoms, and (4) orthopedic deficits. Measurements were performed at four moments in time: (1) preoperatively, (2) postoperatively, (3) follow-up 1 (4.6 years), and (4) follow-up 2 (11.2 years). Besides this, a subgroup analysis and a quality of life questionnaire were performed.

RESULTS

When observing the symptom domains in the long-term, the pain domain appeared to improve most postoperatively after which it remained stable over time. The neurological and urological domains showed a stable, slightly decreasing trend in the long-term follow-up. The orthopedic domain showed a significant increase of the number of patients with scoliosis during the long-term follow-up.

CONCLUSIONS

Lasting effects of stability in the neurological, urological, and pain domains were observed. Close monitoring during follow-up might contribute to early recognition of progressive scoliosis, in spite of detethering, in a risk group defined by females who underwent tethered cord surgery at or under the age of 12 years old with either lipomyelomeningocele, split cord malformation, or myelomeningocele. Detethering does not appear to protect these patients against progressive scoliosis.

Comparison of 3 Different Types of Spinal Arteriovenous Shunts below the Conus in Clinical Presentation, Radiologic Findings, and Outcomes

BACKGROUND AND PURPOSE

Spinal arteriovenous shunts below the conus constitute 3 types of lesions, which have previously been mainly described in case reports, given their rarity, and are sometimes misdiagnosed. The purpose of this study was to describe the features of each type and compare these types as to epidemiologic features, clinical and radiologic presentations, treatment, and outcomes in a consecutive series of 48 cases.

MATERIALS AND METHODS

The prospectively collected data bases of 2 referral centers for spinal vascular lesions were retrospectively reviewed. Spinal arteriovenous shunts below the conus were defined as all dural and intradural shunts below the conus medullaris. Clinical features, radiologic findings, treatment results, and clinical outcomes were assessed.

RESULTS

There were filum terminale arteriovenous fistulas in 11 patients (22.9%), radicular arteriovenous shunts in 7 patients (14.6%), and spinal dural arteriovenous fistulas in 30 patients (62.5%). Radicular arteriovenous shunts presented at a younger age (P = .017) and with a higher incidence of back pain symptoms (P = .037). A tethered spinal cord was found in 54.5% of patients with filum terminale arteriovenous fistulas and 23.3% of patients with spinal dural arteriovenous fistulas. After treatment, the angiographic complete obliteration rate was 89.4% and spinal function was improved significantly (P < .001).

CONCLUSIONS

Three groups of spinal arteriovenous shunts below the conus can be differentiated according to clinical and radiologic features. Filum terminale arteriovenous fistulas are frequently associated with dysraphic malformations, which may suggest a particular embryologic origin.

Surgical treatments on adult tethered cord syndrome: A retrospective study

To investigate effects of surgical treatment on adult tethered cord syndrome (TCS).A retrospective analysis of 82 adult patients (17 male cases, 82% and 24 female cases, 59%) with TCS treated by surgery was conducted between March, 2005 and December, 2015, with an average age of 31.6 years and average disease course of 6.7 years. All the 82 cases of patients received nerve electrophysiology monitoring assisted microsurgery. After surgery, all patients were followed up for an average of 2.5 years. Surgical effects were evaluated according to Hoffman grading system. As this is just a retrospective study that does not involve any interventions, ethical approval was not necessary according to the rules of the hospital.All patients were followed up, no death occurred. According to Hoffman grading system, the neurologic symptoms were improved in 22 patients (27%), stabilized in 60 patients (73%). Of 10 cases with lipoma tethered spinal cord, corresponding symptoms were improved in 2 cases. Of 32 cases with tethered spinal cord caused by dermoid cyst and epidermoid cyst, the symptoms were improved in 6 cases. Of 40 cases without occupying lesions of tethered spinal cord, the symptoms were improved in 14 cases. Besides, there was no deteriorated case.Surgical treatment on adult patients with TCS can improve the neurologic deficits which are associated with the course of disease, early treatment has much better curative effect.

Spinal cord stimulation for recurrent tethered cord syndrome in a pediatric patient: case report

The authors present a patient with a lipomyelomeningocele and worsening back pain due to recurrent tethered cord syndrome. Because of the increased risk and unlikely improvement in symptoms with repeated surgical untethering, she was offered an alternative treatment with a trial of dorsal spinal cord stimulation. She had an excellent response to the percutaneous trial, and a permanent implant was placed, with good initial results. The authors review her case as well as the treatment options, indications, and outcomes for recurrent tethered cord syndrome.

Early urologic considerations in patients with persistent cloaca

Cloacal malformations represent one of the most complex conditions among anorectal malformations. Urologic conditions occur with an increased frequency in cloaca patients compared to patients with other types of ARM. The morbidity of the upper and lower urinary tract dysfunction/malformations at times can be severe; manifested by urinary tract infection, lower urinary tract symptoms, urinary incontinence, chronic kidney disease, and even end stage renal disease. Long-term follow-up of patients with cloaca has described significant chronic kidney disease and end-stage renal disease. Whether this rate of chronic kidney disease is a function of intrinsic renal dysplasia or acquired renal injury from neurogenic bladder is currently unknown. However, it is well known that severe lower urinary tract dysfunction, no matter the etiology, poses significant risk to the upper tracts when untreated. Neonatal assessment of the urinary tract accompanied by early identification of abnormal structure and function is therefore fundamental to minimize the impact of any urologic condition on the child's overall health. Adequate management of any associated bladder dysfunction is essential to preserving renal function, minimizing risk of urinary tract infection, and potentially avoiding need for future reconstructive surgery. This article summarizes our institution's approach to the ongoing early urologic management in patients with cloaca.

Fecal incontinence as a predominant symptom in a case of multiply recurrent tethered cord: diagnosis and operative strategies

Recurrent manifestations of tethered spinal cord after an initial operative intervention for a simple fatty filum terminale is fairly uncommon. The authors present the case of an unusual clinical course in which there were 3 distinct episodes of recurrence, each time presenting predominantly as fecal incontinence and resolving with operative intervention. Typical signs of tethering were absent on radiological evaluation, and operative intervention was based on clinical grounds. Intraoperatively, sacral nerve roots to the anal sphincter were found tethered to the filar stump with electrophysiological evidence of regained activity on disentanglement. To the best of the authors' knowledge, a similar clinical course or operative findings have not been reported.

Prenatal Evaluation of the Fetal Conus Medullaris on a Routine Scan

Objective: To assess the ability to identify the conus medullaris (CM) and measure the conus-sacrum distance (CS distance) on a routine scan and the relationship with maternal and fetal factors. Methods: This was a prospective study. The assessment of the CM and the CS distance and the influence of the body mass index (BMI), gestational age (GA) and fetal position were analyzed. The correlation between the femur length (FL) and the GA with the CS distance was evaluated. Results: A total of 696 fetuses were analyzed. The CM could be visualized in 82.3% of the cases, and the CS distance could be analyzed in 81.2% of the cases. The CM assessment was statistically associated with BMI and fetal position but not with GA. The CS distance assessment was statistically associated with BMI and GA but not with fetal position. We determined a significant association between the FL/CS distance and between the GA/CS distance. Conclusions: Assessment of the CM is possible on most routine scans. The CS distance could be introduced to routine scans for the assessment of prenatal skin-covered spinal dysraphism. High BMI, advanced GA and breech presentation could be potential factors limiting the feasibility of evaluating the CM.

Perineal pain secondary to tethered cord syndrome: retrospective review of single institution experience

OBJECT

Tethered cord syndrome (TCS) encompasses a spectrum of neurological dysfunction related to excessive tension on the distal spinal cord resulting in anatomic deformation and metabolic disturbance. Symptoms typically manifest as back/leg pain, neurogenic bladder dysfunction, constipation, sphincter abnormalities, and scoliosis. To date, among the least well-described symptoms of TCS is pain or hypersensitivity in the perineal region. The authors reviewed their experience with spinal cord detethering to identify and further characterize those who present with perineal pain or hypersensitivity.

METHODS

Cases of spinal cord detethering at a single institution were retrospectively reviewed. Patients were initially identified by procedural codes. Cases were reviewed for presenting symptoms, specifically perineal pain or hypersensitivity. Magnetic resonance image (MRI) findings, clinical outcome, and length of follow-up were also noted.

RESULTS

Of the 491 patients identified, seven patients (1.4%) were identified as having preoperative perineal pain or hypersensitivity. All of these patients had complete resolution of perineal pain/hypersensitivity at the time of last follow-up. Furthermore, five (71%) of these patients experienced resolution of all initial symptoms.

CONCLUSION

Perineal pain or hypersensitivity can be an important symptom of spinal cord tethering. Spinal cord detethering may result in a good outcome and relief of perineal pain or hypersensitivity.