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Naseri Alavi SA, Fluss R, Lehner K, Judy B, Groves M, Cohen A, Kobets AJ. Tethered cord prevalence among patients with prenatal or postnatal myelomeningocele repair. Childs Nerv Syst 2024:10.1007/s00381-024-06584-5. [PMID: 39356312 DOI: 10.1007/s00381-024-06584-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 08/19/2024] [Indexed: 10/03/2024]
Abstract
BACKGROUND Myelomeningocele (MMC) is a severe form of spina bifida characterized by spinal cord extrusion into a cerebrospinal fluid (CSF) filled sac which may lead to lifelong disability. Repair of these lesions have classically occurred shortly after birth, but more recently, prenatal myelomeningocele repair techniques have been elucidated. This study aimed to investigate the outcome of surgery, particularly with subsequent spinal cord tethering, in patients with prenatal myelomeningocele closure and those with postnatal repair surgery. MATERIALS AND METHODS In this retrospective study which assessed patients from April 2002 to April 2020, the data of 18 total patients with MMC were reviewed. Nine patients from each group were included, closed prenatally or postnatally, respectively. Demographic information including age and sex, birth week, infant comorbidities, presence of dermoid or lipoma, cutaneous stigmata, total number and timing of detethering procedures, presence of Chiari malformation, and need for VPS was obtained. RESULTS Eighteen patients including nine infants closed prenatally and nine infants with myelomeningoceles closed postnatally were reviewed. The mean age was 4 ± 3 years and 6.22 ± 2.4 in prenatal and postnatal retrospectively. There was a significant relationship between the number of detethering procedures (p-value = 0.03) and the need for a ventriculoperitoneal shunt (VPS) (p-value = 0.01) between the groups, with the prenatal closure group having lower rates of each. There was no significant difference between the groups in regard to the mean age at the detethering procedure (p = 0.4), sex (p = 0.09), birth week (p = 0.8), comorbidities (p = 0.8), presence of intraspinal dermoid or lipoma (p = 0.09), presence of cutaneous stigma (p = 0.08), Chiari (p = 0.6), fatty filum (p = 0.08), syrinx (p = 0.4), bone anomaly (p = 0.4), and spina bifida neurological scale (p = 0.66). CONCLUSION There was a significant relationship between the two groups in terms of the number of detethering procedures, and the need for VPS. Our data represents a possible difference in the need for detethering surgeries and ventriculoperitoneal shunt placements between patients with prenatal and postnatal myelomeningocele closures.
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Affiliation(s)
- Seyed Ahmad Naseri Alavi
- Department of Neurological Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, 10467, USA.
- School of Medicine, Department of Neurosurgery, Emory University, Atlanta, USA.
| | - Ross Fluss
- Department of Neurological Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Kurt Lehner
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brendan Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mari Groves
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alan Cohen
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew J Kobets
- Department of Neurological Surgery, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY, 10467, USA
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Kondo A, Kamihira O, Itoh T, Gotoh M, Kato K. A 31-year follow-up of those with occult spinal dysraphism, who underwent spinal cord untethering: Lower urinary tract function, skin stigmata, fertility, and work participation. Int J Urol 2024; 31:819-824. [PMID: 38634346 DOI: 10.1111/iju.15467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/01/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES This study evaluated patients with occult spinal dysraphism who underwent spinal cord untethering. METHODS Twenty-four patients who visited us between 1983 and 2000 were followed-up for a mean duration of 31 years. We studied their lower urinary tract function, skin stigmata, fertility, and work participation. RESULTS Questionnaires sent in 2022 revealed that 5 patients had normal voiding (Group A) and 19 patients had abnormal voiding (Group B). Groups A and B underwent spinal cord untethering at a mean age of 5.7 and 13.0 years, respectively, showing a significant statistical difference (p = 0.036). After spinal cord untethering, the number of patients with detrusor normoactivity increased from 0 to 5, i.e., 3 of 6 with detrusor overactivity (50%), 1 of 2 not examined, and 1 of 5 not known. Patients with detrusor underactivity also increased from 11 to 19. Severity of incontinence in the International Consultation on Incontinence Questionnaire-Short Form resulted in a mean value of 2.4 in Group A, which was significantly superior to the mean value of 9.1 in Group B (p = 0.004). Fourteen patients (58.3%) were married and had 21 healthy children. A majority of patients have had full-time jobs. A variety of skin stigmata were present in the lumbosacral region, and changes in vesico-urethral configurations were observed during a video-urodynamic study. CONCLUSIONS Our study identified that the early timing of spinal cord untethering performed in neonates or infants and detrusor overactivity prior to untethering surgery are important factors in achieving normal bladder function.
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Affiliation(s)
- Atsuo Kondo
- Department of Urology, Atsuta Rehabilitation Hospital, Nagoya, Japan
| | - Osamu Kamihira
- Department of Urology, Komaki Municipal Hospital, Komaki, Japan
| | - Tomonori Itoh
- Department of Internal Medicine, Atsuta Rehabilitation Hospital, Nagoya, Japan
| | | | - Kumiko Kato
- Department of Female Urology, Meitetsu Hospital, Nagoya, Japan
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Sekido N. Editorial Comment to 31-year follow-up of those with occult spinal dysraphism who underwent spinal cord untethering: Lower urinary tract function, skin stigmata, fertility, and work participation. Int J Urol 2024; 31:825. [PMID: 38693659 DOI: 10.1111/iju.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Noritoshi Sekido
- Department of Urology, Toho University Ohashi Medical Center, Tokyo, Japan
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Abu-Ata MM, Pasquali C, Sala F. Intraoperative Neuromonitoring in Tethered Cord Surgery in Children. J Clin Neurophysiol 2024; 41:123-133. [PMID: 38306220 DOI: 10.1097/wnp.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024] Open
Affiliation(s)
- Mahmoud M Abu-Ata
- Center of Neurosciences, King Faisal Specialty Hospital and Research Center, Riyadh, Saudi Arabia; and
| | - Claudia Pasquali
- Department of Neurosciences, Institute of Neurosurgery, University Hospital, Verona, Italy
| | - Francesco Sala
- Department of Neurosciences, Institute of Neurosurgery, University Hospital, Verona, Italy
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Ren F, Bressler L, Pruitt L, Wang H, Liu L, Elston DM. Midline cutaneous anomalies of the craniospinal axis. J Am Acad Dermatol 2023; 89:1238-1244. [PMID: 37598328 DOI: 10.1016/j.jaad.2023.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/28/2023] [Accepted: 06/26/2023] [Indexed: 08/21/2023]
Abstract
Patients with midline cutaneous anomalies of the craniospinal axis can be indicative of underlying embryonic defects, such as neural tube defects. Lack of familiarity with these midline aberrant skin findings may lead to misdiagnosis and delayed treatment. In this review, midline cutaneous anomalies of the craniospinal axis including aplasia cutis congenita, cranial and spinal dysraphism, and other developmental anomalies are explored in detail with emphasis on cutaneous clues to the diagnosis and appropriate workup.
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Affiliation(s)
- Faliang Ren
- Department of Dermatology, Children's Hospital of Chongqing Medical University, Chongqing, China; Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Lindsey Bressler
- Department of Dermatology & Dermatological Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Laura Pruitt
- Department of Dermatology & Dermatological Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Hua Wang
- Department of Dermatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Liu
- Department of Dermatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Dirk M Elston
- Department of Dermatology & Dermatological Surgery, Medical University of South Carolina, Charleston, South Carolina
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Schatteman S, Jaremko J, Jans L, Herregods N. Update on Pediatric Spine Imaging. Semin Musculoskelet Radiol 2023; 27:566-579. [PMID: 37816365 DOI: 10.1055/s-0043-1771333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors.
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Affiliation(s)
- Stijn Schatteman
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jacob Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lennart Jans
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
| | - Nele Herregods
- Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium
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Keykhosravi E, Faravani E, Dehghani Dashtabi S, Emadzadeh M, Alamdaran SA, Aminzadeh B. Comparison of Ultrasonographic Findings between Patients with Tethered Cord Syndrome and Healthy Children. IRANIAN JOURNAL OF MEDICAL SCIENCES 2023; 48:130-136. [PMID: 36895465 PMCID: PMC9989241 DOI: 10.30476/ijms.2022.93848.2517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 03/23/2022] [Indexed: 03/11/2023]
Abstract
Background Tethered cord syndrome (TCS) is a type of occult spinal dysraphism, which necessitates early detection as an essential component of patient management in reducing complications. This study aimed to compare the findings of spinal cord ultrasonography between TCS patients and healthy individuals. Methods The current study is a case-control study of patients who were admitted to the Akbar and Ghaem Hospitals (Mashhad, Iran) in 2019. The study population comprised 30 children with TCS aged under two years old, and the control group included 34 healthy peers of the same age. The maximum distance of the spinal cord from the posterior canal wall was measured in millimeters using ultrasonography. Demographic and sonographic findings of each participant were recorded in checklists, which were then entered into SPSS software. P values less than 0.05 were considered statistically significant. Results The study included 30 children with TCS and 34 healthy individuals with a mean age of 7.67±6.39 months. TCS patients had a significantly shorter maximum distance of the spinal cord from the posterior wall of the spinal canal than the control group (1.75±0.62 mm vs. 2.79±0.76, P<0.001). After performing corrective surgery, the TCS patients indicated significant improvement in this interval (1.57±0.54 mm to 2.95±0.49 mm, respectively, P=0.001). Conclusion In comparison to children without TCS, the spinal cord was substantially closer to the posterior canal wall in TCS patients. However, these outcomes were improved significantly in patients after surgery.
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Affiliation(s)
- Ehsan Keykhosravi
- Department of Neurosurgery, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elham Faravani
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Maryam Emadzadeh
- Clinical Research Development Unit, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Ali Alamdaran
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad Aminzadeh
- Department of Radiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Mualem W, Nathani KR, Durrani S, Zamanian C, Ghaith AK, Michalopoulos GD, Rotter J, Daniels D, Bydon M. Utilizing pre- and postoperative radiological parameters to predict surgical outcomes following untethering for tethered cord syndrome in a pediatric population. J Neurosurg Pediatr 2023; 31:159-168. [PMID: 36461831 DOI: 10.3171/2022.10.peds22459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Tethered cord syndrome (TCS) can lead to significant downstream neurological deficits including gait deterioration, incontinence, and often unexplained chronic low-back pain. Surgical intervention may relieve symptoms, but there are no defined radiological parameters associated with surgical outcomes and functional status. The authors aimed to define pre- and postoperative radiological parameters for assessing surgical outcomes in TCS. METHODS The authors performed a single-center retrospective review of all pediatric patients treated for TCS between 2016 and 2021. Patient baseline characteristics and operative metrics included age, sex, level of conus, level of procedure, tethering pathology, symptoms at presentation, complications, improvement of symptoms, and reoperation rate. MRI measurements included pre- and postoperative anterior canal distance (ACD) and bending angle (BA). RESULTS Thirty-three pediatric patients were identified who underwent untethering of the spinal cord and had pre- and postoperative MRI between 2016 and 2021. The mean patient age was 5.64 ± 5.33 years. Twenty patients (60.60%) were female. Regarding the site of untethering, 31 procedures (93.93%) were performed at the lumbosacral region and 2 (6.06%) were performed at the thoracolumbar region. The conus medullaris was found above L3 in 21.21% of patients. Postoperatively, 18.18% of patients experienced complications, 48.48% showed improvement in their symptoms, and 48.48% were equivocal or had persistent symptoms. The mean preoperative ACD0 (measured from the posterior vertebral body margin [middle] to the anterior margin of the conus medullaris) was 6.15 ± 3.18 mm, the postoperative ACD0 was 2.25 ± 2.72 mm, and the average change in ACD0 was -0.90 ± 1.31 mm. The mean preoperative BA was 26.00° ± 11.56°, the mean postoperative BA was 15.92° ± 9.81°, and the average change in BA was -10.08° ± 8.80°. An optimal cutoff value for preoperative BA to predict reoperation in pediatric patients with complex TCS undergoing surgery was ≥ 31.70° (area under the curve = 0.83). CONCLUSIONS In surgically treated patients with TCS, certain preoperative radiological parameters may be important in predicting postoperative surgical outcomes; these parameters can be evaluated and reported to indicate patients at high risk for complications. Further prospective multicenter research is warranted to offer robust evidence of association of patient outcomes with preoperative radiological parameters in TCS.
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Affiliation(s)
- William Mualem
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karim Rizwan Nathani
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sulaman Durrani
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cameron Zamanian
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Abdul Karim Ghaith
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Giorgos D Michalopoulos
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Juliana Rotter
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - David Daniels
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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Abstract
Micturition requires complex interplay involving bladder, peripheral neural network, spinal cord, and brain. Spinal dysraphism presents variety of neural lesions that may affect this interplay leading to neurogenic bladder. However, the diagnosis of neurogenic bladder in those with spinal dysraphism is often difficult and contrasted to other types of neurogenic bladder caused by complete neural lesions such as spinal cord injury or brain tumor. Typically, neurogenic bladder caused by spinal dysraphism shows lower motor neuron lesion and partial neural injury. However, upper motor signs can be seen with the occurrence of tethered cord syndrome and developmental immaturity of bladder control often complicated by fecal impaction. Thus, the diagnosis of tethered cord syndrome should be made cautiously. Several invasive and noninvasive diagnostic modalities could be applied for accurate diagnosis, preventing renal damage and controlling urinary incontinence. However, it should be borne in mind that no single study is definitive for accurate diagnosis, so it requires careful scrutiny in interpretation. The follow-up scheme of these patients should be determined to detect urological deterioration due to the development of tethered cord syndrome. Since the development of tethered cord syndrome shows diverse nature implicating urological and orthopedic issues, multidisciplinary collaboration is essential for comprehensive care.
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Affiliation(s)
- Kwanjin Park
- Department of Urology, Seoul National University, College of Medicine, Seoul, Republic of Korea.
- Division of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Republic of Korea.
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Hung JW, Chow JS, Kuok MC, Lam AK, Lee JL, Yam FS, Chung KL, Wu SP, Cheung FC, Chan WK, Leung MW. Correlation of urodynamic studies and somatosensory evoked potential and their prognostic value in children with closed spinal dysraphism. J Pediatr Urol 2022; 19:193.e1-193.e8. [PMID: 36566130 DOI: 10.1016/j.jpurol.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Somatosensory evoked potential (SSEP) and urodynamic studies (UD) are valuable tools for assessing patients with closed spinal dysraphism (CSD) before neurosurgical intervention. No studies have correlated their findings in this cohort and our aim is to study their correlation and prognostic value in pediatric patients with closed spinal dysraphism. METHODS Retrospective review of all patients referred to a multidisciplinary clinic in a tertiary pediatric surgical center over a 17 years period between April 2004 to September 2021 was performed. Inclusion criteria were <18 years old, diagnosed with CSD, with SSEP and UD done within 1 year of each other. Demographics data collected include age at presentation/at referral/at neurosurgical operation, gender, symptoms at presentation and intra-operative diagnoses. Pre-operative SSEP and UD findings were documented. Primary outcome was UD results in the group with normal and abnormal SSEP. Secondary outcome was urological and bowel function outcome in 4 groups of patients (Group A-both normal SSEP and UD, Group B- abnormal SSEP only, Group C - abnormal UD only and Group D-both abnormal SSEP and UD). RESULTS A total of 45 patients were included for analysis. Mean follow up time was 118.9 months (24-216 months, SD 55.8 months). SSEP was normal in 20 patients and abnormal in 25 patients. Baseline demographics, preoperative symptoms and imaging were similar between 2 groups. Primary outcome Patients with abnormal SSEP were more likely to have abnormal UD results with a statistically significant difference (84% vs 40%, p < 0.05). They have a significantly higher end-fill detrusor pressure (12% vs 0%, p < 0.05), abnormal bladder compliance (20% vs 0%, p < 0.05), abnormal cystometric capacity (48% vs 10%, p < 0.05), poor emptying efficiency (24% vs 5%, p < 0.05) and sphincter incompetence (8% vs 0%, p < 0.05). Secondary outcome When compared to Groups A to C, patients in group D were more likely to be on anti-cholinergic (33.3% vs 4.3%, p < 0.05), required clean intermittent catheterization (42.9% vs 4.3%, p < 0.05) and had intravesical botulinum injection (19% vs 0%, p < 0.05). All the patients who had augmentation cystoplasty were in this group as well. Bowel function in terms of regular enema use was also statistically significantly higher in this group (33.4% p < 0.05). CONCLUSION Pre-operative SSEP and UD results correlate well in patients with closed spinal dysraphism. Patients with abnormal SSEP and UD preoperatively have higher risk of urological deterioration over time. Close monitoring in this group is warranted.
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Affiliation(s)
- Judy Ws Hung
- Department of Surgery, Hong Kong Children's Hospital, Hong Kong.
| | - Joyce Sw Chow
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong
| | - Manson Ci Kuok
- Department of Paediatrics and Adolescent Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Alva Kf Lam
- Department of Paediatrics and Adolescent Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Joseph Ly Lee
- Department of Surgery, Hong Kong Children's Hospital, Hong Kong
| | - Felix Sd Yam
- Department of Surgery, Hong Kong Children's Hospital, Hong Kong
| | | | - Shun Ping Wu
- Department of Paediatrics and Adolescent Medicine, Queen Elizabeth Hospital, Hong Kong
| | | | - Winnie Ky Chan
- Department of Paediatrics and Adolescent Medicine, Queen Elizabeth Hospital, Hong Kong
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Electrodiagnosis has a potential to identify neural damage in asymptomatic infants with closed spinal dysraphism. Childs Nerv Syst 2022; 39:1005-1012. [PMID: 36445470 DOI: 10.1007/s00381-022-05777-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/23/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE The presence and progression of symptoms is the basis for deciding to perform surgery in infants with closed spinal dysraphism (CSD); however, identifying symptoms could be limited, making it difficult to decide. This study investigated whether an electrodiagnostic study (EDS) can provide evidence of neural damage in asymptomatic infants with CSD. METHODS The study group comprised infants with CSD suspected of having neural damage based on structural abnormalities in spinal ultrasound findings. The patients' medical records were reviewed retrospectively for their clinical presentation, neuroimaging findings, urodynamic study (UDS) results, EDS findings, and surgical status. RESULTS Among 125 infants who underwent EDS and UDS, 117 (94%) had no clinical symptoms, except for cutaneous manifestations. Among these asymptomatic patients, 51 individuals (43.6%) had abnormal EDS findings; 33 subjects (28.2%) showed abnormal findings on EDS alone, while 37 (31.6%) on UDS alone, and 18 (15.4%) on both EDS and UDS. Chi-square test showed an opposite relationship between the two test results; when EDS was abnormal, UDS was often normal and vice versa (χ2 = 5.328, p = 0.021). In all cases with abnormal EDS, denervation potentials, such as fibrillation and positive sharp waves, were observed on needle electromyography. However, abnormal findings in the nerve conduction study were observed only in six cases. CONCLUSION Subclinical neural damage was identified through EDS in asymptomatic infants with CSD. EDS could be necessary to determine whether follow-up monitoring only or surgical intervention is required for this patient group complementing UDS findings.
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Petronic Markovic I, Nikolic D, Stahl M, Tederko P, Hdyrya O, Negrini S, Zampolini M, Kiekens C. Evidence-based position paper of the UEMS PRM on the role of Physical and Rehabilitation Medicine (PRM) physician in the management of children and adults with spinal dysraphism. Eur J Phys Rehabil Med 2022; 58:511-519. [PMID: 35575455 PMCID: PMC9980507 DOI: 10.23736/s1973-9087.22.07536-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spinal dysraphism (SD) or spina bifida (SB) is a congenital deformity that results from embryonic neural tube closure failure during fetal development. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section. This paper aims to evaluate the role of the physical and rehabilitation medicine (PRM) physician and PRM practice for children and adults with spinal dysraphism. A systematic literature review and a consensus procedure involved all European countries delegates represented in the UEMS PRM section through a Delphi process. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The professional role of the PRM physician requires specific expertise in the treatment of patients with SD to plan, lead and monitor the rehabilitation process in an interdisciplinary setting and to participate in the assessment of the needs of these patients in the transitional phase from childhood to adulthood, with particular attention to the activity limitation and participation restriction.
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Affiliation(s)
- Ivana Petronic Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Physical Medicine and Rehabilitation, University Children's Hospital, Belgrade, Serbia
| | - Dejan Nikolic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia - .,Department of Physical Medicine and Rehabilitation, University Children's Hospital, Belgrade, Serbia
| | - Minna Stahl
- National Center for Pediatric and Adolescent Pain Management and Research, New Children's Hospital, HUS, Helsinki, Finland
| | - Piotr Tederko
- Department of Rehabilitation, Medical University of Warsaw, Warsaw, Poland
| | - Oksana Hdyrya
- Department of Rehabilitation and Alternative Medicine, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Stefano Negrini
- La Statale University, Milan, Italy.,IRCCS Galeazzi Orthopedic Institute, Milan, Italy
| | - Mauro Zampolini
- Department of Rehabilitation, San Giovanni Battista Hospital, Foligno, Perugia, Italy
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Morizawa Y, Satoh H, Arai M, Iwasa S, Sato A, Fujimoto K. Urodynamics findings pre- and post-untethering surgery in children with filum lipoma: A single-institution experience. Int J Urol 2022; 29:884-889. [PMID: 35596566 DOI: 10.1111/iju.14931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/27/2022] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We aimed to investigate the changes in urodynamics and voiding cystourethrogram parameters on pre- and post-untethering surgery in patients aged under 2 years with filum lipoma. METHODS Sixty-two patients were enrolled in this study. The changes in urodynamics and voiding cystourethrogram parameters were compared before untethering surgery and 6 months after untethering surgery. These parameters were bladder volume, bladder deformity, vesicoureteral reflux during voiding cystourethrogram, detrusor overactivity, bladder compliance, and post-void residual volume in urodynamics. RESULTS Bladder volume during voiding cystourethrogram and bladder compliance increased significantly from 89.8 ± 49.5 mL to 114.5 ± 50.5 mL (P = 0.0069) and 10.2 ± 6.2 mL/mmH2 O to 17.0 ± 13.3 mL/mmH2 O (P = 0.0008), respectively, at 6-month follow-up. Six patients required combination management with clean intermittent catheterization at 25.1 ± 8.2 months (14.3 ± 6.5-months follow-up) because of elevated post-void residual volumes. CONCLUSIONS According to voiding cystourethrogram results, bladder function and urodynamics in patients with filum lipoma significantly improved after untethering surgery. Non-invasive assessment based on measurements of post-void residual should be considered as a postoperative follow-up method.
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Affiliation(s)
- Yosuke Morizawa
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroyuki Satoh
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masashi Arai
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shun Iwasa
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Atsuko Sato
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
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14
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Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change. ANTHROPOLOGICAL REVIEW 2022. [DOI: 10.18778/1898-6773.85.2.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Substantial relaxation of natural selection beginning around 1900 changed the mutation/selection balance of modern genetic material, producing an increase in variable anatomical structures. While multiple structures have been affected, the temporal increase in variations of the sacrum, specifically, ‘Sacral Spina Bifida Occulta,’ have been reliably demonstrated on a localised scale. Calculation of largescale frequency has been hindered by the localised nature of these publications, the morphological variability of this variation, and potential pathological associations, which have produced divergent classifications, and conflicting reported rates of occurrence. A systematic review of the reported literature was conducted to provide an objective analysis of Sacral Spina Bifida Occulta frequency from 2500 BCE to the present. This review was designed to compensate for observed inconsistencies in reporting and to ascertain, for the first time, the temporal trajectory of this secular trend. A systematic review of Sacral Spina Bifida Occulta literature was conducted through the strict use of clinical meta-analysis criteria. Publications were retrieved from four databases: PubMed, Embase, the Adelaide University Library database, and Google Scholar. Data were separated into three historical groups, (1 = <1900, 2 = 1900 to 1980 and 3 = >1980), and frequency outcomes compared, to determine temporal rates of occurrence.
A total of 39/409 publications were included in the final analysis, representing data for 16,167 sacra, spanning a period of 4,500 years. Statistically significant results were obtained, with total open S1 frequency increasing from 2.34%, (79 to 1900CE), to 4.80%, (1900 to 1980CE) and to 5.43% (>1980CE). These increases were significant at p<0.0001, with Chi-squared analysis. A clear secular increase in the global frequency of Sacral Spina Bifida Occulta has been demonstrated from 1900 to the present. This research provides a novel and adaptable framework for the future assessment of variation distribution, with important implications for the fields of biological anthropology and bioarchaeology.
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15
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Edström E, Wesslén C, Fletcher-Sandersjöö A, Elmi-Terander A, Sandvik U. Filum terminale transection in pediatric tethered cord syndrome: a single center, population-based, cohort study of 95 cases. Acta Neurochir (Wien) 2022; 164:1473-1480. [PMID: 35482074 PMCID: PMC9160100 DOI: 10.1007/s00701-022-05218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/19/2022] [Indexed: 12/02/2022]
Abstract
Purpose The purpose of this study was to evaluate outcome following surgical transection of filum terminale (FT) in symptomatic and asymptomatic pediatric patients with radiological findings consistent with tethered cord syndrome (TCS). Methods Patients < 17 years who underwent untethering surgery between 2007 and 2018 were screened for eligibility. Those who had undergone primary transection of the FT, and had preoperative radiological findings of fatty filum, thickened FT, or low-lying conus, below the pedicles of L2, were included. The cohort was divided into symptomatic and asymptomatic depending on clinical presentation. Surgical complications and functional outcome was recorded. Results In total, 95 patients were included, of whom 62 were symptomatic. In symptomatic patients, the main indications for radiological evaluation were scoliosis (29%) and motor symptoms (19%). In asymptomatic patients, skin stigmata (76%) were the most common finding. Fatty or thick FT was the most common radiographic finding, seen in 61% of symptomatic and 79% of asymptomatic cases. All patients underwent transection of the FT and were followed for a median of 1.8 years. A postoperative complication occurred in 12%, all Ibanez type Ib and managed without invasive treatment. For the symptomatic cohort, significant improvement was seen for both urodynamic assessment (48% improved, p = 0.002) and sensorimotor function (42% improved, p < 0.001). Conclusions Neurological improvement or halted deterioration was seen in the majority of symptomatic cases. Asymptomatic patients did not experience any severe complications. Filum transection should be offered to symptomatic and asymptomatic patients upon diagnosis of fatty filum, thickened FT, or low-lying conus.
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16
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Xu K, He J, Wang L. A systematic review and meta-analysis of minimally invasive surgery in children with occult tethered cord syndrome. Transl Pediatr 2022; 11:403-410. [PMID: 35378968 PMCID: PMC8976679 DOI: 10.21037/tp-22-72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND At present, the surgical treatment of occult tethered cord syndrome (OTCS) in children is mostly two types of minimally invasive surgery: filum terminalis laxity or filum terminalectomy. The clinical efficacy and safety of minimally invasive treatment and conservative treatment are still unclear. Therefore, this study will use the advantages of systematic review and meta-analysis to evaluate the objectivity, and explore the effect of minimally invasive surgery on children with occult tethered cord syndrome. METHODS A computer search was used to search PubMed, Embase, CNKI, Wanfang Database and other literature search websites about the randomized controlled trials (RCTs) of minimally invasive surgery in children with occult tethered cord syndrome and spinal lipoma. Professional journals were manually searched to avoid omissions. The search keywords were: occult myelolipoma, occult tethered cord syndrome, surgical treatment of tethered cord syndrome, occult tethered cord syndrome. RESULTS A total of 6 relevant literatures that could be used for meta-analysis were selected. A total of 425 subjects were included in the article, of which 132 were treated conservatively and 293 were treated surgically. The heterogeneity detection test statistics of the included studies were Chi2 (Chi-squared test) =8.18, df (degree of freedom) =5, I2=39%<50%, Z=2.53, and the homogeneity of the included studies was good. The number of unimproved cases under conservative treatment was 40, accounting for 30.30%; the number of unimproved cases under surgical treatment was 33, accounting for 11.26%, and the total unimproved rate of the two groups accounted for 17.17%. The unimproved rate of the experimental group was significantly lower than that of the control group, and the difference was statistically significant (P=0.01). The results of bias analysis showed that there was no significant bias in the literature included in this study. DISCUSSION Meta-analysis results confirmed that minimally invasive surgery has a significant effect on the treatment of occult children with tethered cord syndrome. However, due to the small sample size of the included literature, further evaluation of the treatment risk is required.
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Affiliation(s)
- Ketao Xu
- Pediatric Surgery, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Jianhua He
- Pediatric Surgery, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Leibo Wang
- Pediatric Surgery, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
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17
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Klinge PM, Srivastava V, McElroy A, Leary OP, Ahmed Z, Donahue JE, Brinker T, De Vloo P, Gokaslan ZL. Diseased filum terminale as a cause of tethered cord syndrome in Ehlers Danlos syndrome: histopathology, biomechanics, clinical presentation, and outcome of filum excision. World Neurosurg 2022; 162:e492-e502. [DOI: 10.1016/j.wneu.2022.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
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18
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Cheng L, Wang L, Yao Q, Ma L, Duan W, Guan J, Zhang C, Wang K, Liu Z, Wang X, Wang Z, Wu H, Chen Z, Jian F. Clinicoradiological characteristics of primary spinal cord H3 K27M-mutant diffuse midline glioma. J Neurosurg Spine 2022; 36:303-314. [PMID: 34560639 DOI: 10.3171/2021.4.spine2140] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Primary spinal cord H3 K27M-mutant diffuse midline glioma (DMG) is a rare and devastating pathological entity. However, little attention has been paid to this disease. As a result, its clinicoradiological characteristics have yet to be described. The aim of this study was to describe the clinicoradiological characteristics of primary intramedullary H3 K27M-mutant DMG and to compare this tumor with the H3 K27 wild-type to explore potential features that could differentiate the two. METHODS A total of 59 patients with pathologically confirmed intramedullary astrocytoma were included in this study. The cohort was divided into an H3 K27M-mutant group and H3 K27 wild-type group based on the status of H3 K27M according to an immunohistochemistry method. Demographic data, MRI features, and molecular information were collected. Multivariate logistic regression was conducted to investigate variables that might have a role in differentiating an H3 K27M DMG from an H3 K27 wild-type tumor. RESULTS Only symptom duration showed an independent association with the H3 K27M mutation (OR 0.82, 95% CI 0.68-0.94, p = 0.016). Patients with spinal cord H3 K27M-mutant DMG had a shorter symptom duration than patients with H3 K27 wild-type glioma. No significant difference was found in terms of MRI features between the H3 K27M-mutant and H3 K27 wild-type groups. Additionally, H3 K27M-mutant DMG frequently demonstrated overexpression of p53. Survival outcome did not show a statistical difference between the H3 K27-mutant subgroup and H3 K27 wild-type subgroup in histologically high-grade astrocytoma. CONCLUSIONS Symptom duration was associated with an H3 K27M mutation in intramedullary astrocytoma. MRI features were heterogeneous, and no imaging feature was able to predict the H3 K27M mutation. The H3 K27M mutation did not impact survival outcome in spinal histologically high-grade astrocytoma.
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Affiliation(s)
- Lei Cheng
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Leiming Wang
- 2Department of Pathology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingyu Yao
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Longbing Ma
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Wanru Duan
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Jian Guan
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Can Zhang
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Kai Wang
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Zhenlei Liu
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Xingwen Wang
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Zuowei Wang
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Hao Wu
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Zan Chen
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
| | - Fengzeng Jian
- 1Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing; and
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19
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Yang J, Won JK, Kim KH, Lee JY, Kim SK, Shin HI, Park K, Wang KC. Occult tethered cord syndrome: a rare, treatable condition. Childs Nerv Syst 2022; 38:387-395. [PMID: 34611760 DOI: 10.1007/s00381-021-05353-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Occult tethered cord syndrome (OTCS) is an entity that shows tethered cord syndrome (TCS) with normal spinal MRI findings. The definition and treatment of OTCS have been controversial since first proposal. The purpose of this study was to evaluate the existence, prevalence, histological characteristics, and surgical outcomes of OTCS. METHODS We retrospectively analyzed patients who underwent untethering surgery for OTCS from January 2010 to December 2019. Inclusion criteria were (1) clinical manifestation of TCS; (2) supported by urodynamic study (UDS) or electromyography/nerve conduction study; (3) no structural lesions in the urological tract or spinal cord, and no developmental delay; and (4) postoperative follow-up for > 6 months. Sectioned fila from OTCS patients were histologically compared with those from cases of thickened filum or low-lying conus. RESULTS Five (four female, one male) of 439 patients (1.1%) who underwent untethering surgeries for occult spinal dysraphism corresponded to OTCS. Mean age at the time of surgery was 16 years (7-22 years). Mean postoperative follow-up duration was 45 months (15-114 months). The main symptom was urinary dysfunction in four patients and leg pain in one. All patients had detrusor-sphincter dyssynergia. Fila from OTCS patients revealed increased fibrous tissue as in TCS patients. Four patients showed postoperative improvement and one with preoperative static course had no improvement. CONCLUSIONS This study suggests that OTCS is a definitely existing entity although rare. OTCS is curable when timely treatment is given. Sudden onset with rapid progression of symptom seems the best indication for surgery.
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Affiliation(s)
- Jeyul Yang
- Center for Rare Cancers, Neuro-Oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Gyeonggi-do, 10408, Korea
| | - Jae-Kyung Won
- Department of Pathology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
- Department of Anatomy, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Ki Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - Kwanjin Park
- Division of Pediatric Urology, Seoul National University Children's Hospital, 101 Daehak-no, Jongno-gu, Seoul, 03080, Korea.
| | - Kyu-Chang Wang
- Center for Rare Cancers, Neuro-Oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Gyeonggi-do, 10408, Korea.
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20
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Lee SB, Im YJ, Jung JH, Do MT, Lee JY, Wang KC, Park K. Clinical and urodynamic features of secondary tethered cord syndrome: How can they be found longitudinally? Neurourol Urodyn 2021; 41:365-374. [PMID: 34783385 DOI: 10.1002/nau.24832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/16/2021] [Accepted: 10/22/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE Secondary tethered cord syndrome (TCS) can be diagnosed with signs of progressive deterioration in urological or neuro-orthopedic systems following primary untethering surgery. Though urological deterioration is a common secondary TCS manifestation, a paucity of diagnostic criteria makes diagnoses challenging. A detailed description of urological deterioration may help diagnose secondary TCS. Thus, the clinical and urodynamic features of the current secondary TCS cases were described. MATERIALS AND METHODS Fifty-one patients who had undergone reuntethering for secondary TCS experienced improvement or stabilization of progressive problems. Moreover, their clinical and videourodynamic changes were longitudinally described. RESULTS Loss of postoperative spontaneous voiding was the first urological secondary TCS sign for those who could void spontaneously. Urological problems mostly occurred during elementary school (6-12 years). Major urological presentations were recalcitrant urinary tract infection or urinary incontinence. Follow-up videourodynamic studies revealed typical changes, from acontractile bladder to overactive and low-complaint bladders. While detrusor overactivity did not always occur during the progression, detrusor sphincter dyssynergia was always present in all patients with urological deterioration. All patients postoperatively showed significant urodynamic improvement regardless of preoperative bladder dysfunction. This included four cases of restoring spontaneous voiding. Nine patients experienced newly appearing nonprogressive neuro-orthopedic complications despite their urological improvement. CONCLUSIONS Urological deterioration should prompt secondary TCS suspicion, and changes in clinical patterns and videourodynamic studies helped diagnose it. However, reuntethering can effectively address urological problems at the cost of some neuro-orthopedic functions in some patients.
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Affiliation(s)
- Su B Lee
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, South Korea
| | - Young J Im
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, South Korea
| | - Jae H Jung
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, South Korea
| | - Minh T Do
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, South Korea
| | - Ji Y Lee
- Department of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, South Korea
| | - Kyu-Chang Wang
- Department of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, South Korea
| | - Kwanjin Park
- Department of Pediatric Urology, Seoul National University Children's Hospital, Seoul, South Korea
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21
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Brockman SE, Ottolini KM, Schulz EV. Lumbar Skin Lesion in a Term Infant. Pediatr Rev 2021; 42:624-627. [PMID: 34725223 DOI: 10.1542/pir.2020-001834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Shannon E Brockman
- United States Navy Medicine Readiness and Training Command Okinawa, Okinawa, Japan.,Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD
| | - Katherine M Ottolini
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD.,Department of Neonatology, 18th Healthcare Operations Squadron, Kadena AB, Okinawa, Japan
| | - Elizabeth V Schulz
- Department of Pediatrics, F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD.,Department of Neonatology, 18th Healthcare Operations Squadron, Kadena AB, Okinawa, Japan
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22
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Svokos K, Batista-Silverman L, Graber SJ, O'Neill BR, Handler MH. International survey on the management of lumbosacral cutaneous stigmata in infants with suspected occult spinal dysraphism. J Neurosurg Pediatr 2021; 28:592-599. [PMID: 34479200 DOI: 10.3171/2021.5.peds2126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/21/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Occult spinal dysraphism (OSD) is a common pediatric neurosurgical diagnosis rife with controversy surrounding both the screening of asymptomatic infants and the threshold to offer a prophylactic detethering operation. The authors sought to clarify international practice patterns with a survey of pediatric neurosurgeons. METHODS A survey asked pediatric neurosurgeons whether they would perform imaging in patients with a variety of cutaneous stigmata associated with OSD and whether they would offer prophylactic detethering surgery for asymptomatic patients with a variety of imaging findings on the OSD spectrum. RESULTS Completed surveys were received from 141 pediatric neurosurgeons. Broad consensus was demonstrated on the need for obtaining images in sample patients with more severe stigmata ranging from large lipoma with a skin appendage to focal dysplastic skin in the lumbar midline. Ninety percent of respondents would perform MRI for these patients. In contrast, for patients with a low-sacral dimple, flat hemangioma, and symmetric (Y-shaped) splaying of the intergluteal cleft, opinion on the need for imaging varied considerably (between 57% and 89% recommended imaging). Respondents differed on the type of imaging that they would perform, with 31% to 38% recommending ultrasound screening. The responses reflected less consensus on when to offer surgery to patients with simple spinal tethering (low-lying conus medullaris and fatty filum terminale). Both a lower level of the conus and increased thickness of the filum terminale affected decision-making. CONCLUSIONS The results of this survey showed significant consensus on the recommendation for screening imaging in patients with more dramatic cutaneous stigmata, although these stigmata are the rarest. A significant variance in opinions was reflected in the recommendation for imaging of the most common cutaneous stigmata. Consensus was also lacking on which lesions deserve prophylactic detethering surgery. Significant equipoise exists for future study of screening imaging and of surgical decision-making in patients with asymptomatic OSD and associated cutaneous stigmata.
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Affiliation(s)
| | | | - Sarah J Graber
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Brent R O'Neill
- 2Department of Neurosurgery, University of Colorado, Denver; and
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Michael H Handler
- 2Department of Neurosurgery, University of Colorado, Denver; and
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
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23
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Leopold KN, Ahn ES, Youssef MJ, Gregory SW. Lumbosacral Nevus Simplex in a Newborn Girl with an Asymmetrical Y-Shaped Gluteal Cleft. Pediatr Rev 2021; 42:e41-e44. [PMID: 34599061 DOI: 10.1542/pir.2020-002162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Molly J Youssef
- Department of Pediatric and Adolescent Medicine.,Department of Dermatology, Mayo Clinic, Rochester, MN
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24
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Shields LB, Mutchnick IS, Daniels MW, Peppas DS, Rosenberg E. Risk of occult spinal dysraphism based on lumbosacral cutaneous manifestations. SAGE Open Med 2021; 9:20503121211037172. [PMID: 34394932 PMCID: PMC8358506 DOI: 10.1177/20503121211037172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/16/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives: Occult spinal dysraphism is a congenital failure of fusion of the posterior vertebral arches with intact skin overlying the defect. Lumbosacral cutaneous manifestations are associated with a variable risk of occult spinal dysraphism. Tethered cord syndrome is a type of occult spinal dysraphism that puts abnormal traction on the spinal cord. This study analyzed neonates and infants who were referred to our pediatric urology practice and had evidence of lumbosacral cutaneous manifestation on physical examination. Methods: We reviewed the presence of lumbosacral cutaneous manifestations in neonates and infants evaluated in our pediatric urology clinic at our Institution over a 6-year period (1 March, 2015–28 February, 2021) with no prior diagnosis of lumbosacral cutaneous manifestation. All patients underwent a spinal ultrasound. Results: The most common lumbosacral cutaneous manifestations were bifurcated/duplicated gluteal folds (33%), gluteal asymmetry (19%), and sacral dimples (14%). A total of 34 (24%) patients had an abnormal spinal ultrasound; 15 (44%) of these infants underwent a lumbar magnetic resonance imaging. A coccygeal pit was statistically marginally higher in abnormal versus normal spinal ultrasound (p = 0.07). Patients with only one lumbosacral cutaneous manifestation (N = 121) were significantly more likely to have a normal spinal ultrasound compared to those with two or more lumbosacral cutaneous manifestation (N = 17) (79% vs 53%, p = 0.03). Conclusion: Due to the varying risk of certain lumbosacral cutaneous manifestations with occult spinal dysraphism, all patients with a lumbosacral cutaneous manifestation should undergo spinal ultrasound. This study also highlights the importance of urodynamic studies when there are abnormal cutaneous findings. Routine physical examinations of the lumbar region for cutaneous manifestations of occult spinal dysraphism are vital to ensure prompt management of tethered cord syndrome and avoid potentially devastating consequences.
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Affiliation(s)
- Lisa Be Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, USA
| | - Ian S Mutchnick
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, USA
| | - Michael W Daniels
- Department of Bioinformatics & Biostatistics, University of Louisville, Louisville, KY, USA
| | - Dennis S Peppas
- Norton Children's Urology, Norton Healthcare, Louisville, KY, USA
| | - Eran Rosenberg
- Norton Children's Urology, Norton Healthcare, Louisville, KY, USA
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25
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Thompson DNP, Spoor J, Schotman M, Maestri S, Craven CL, Desai D. Does conus morphology have implications for outcome in lumbosacral lipoma? Childs Nerv Syst 2021; 37:2025-2031. [PMID: 33604718 DOI: 10.1007/s00381-021-05081-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/08/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Lumbosacral lipomas (LSL) of the 'dorsal' type have been associated with more favourable outcomes compared with other conus region lipomas. We hypothesised that integrity of the conus on MRI underpins the improved prognosis in this subgroup of LSL patients. METHODS The definition of 'dorsal lipomas' included lipomas with attachment to the conus, but where the conus could be delineated on MRI (Morota type 1) as reported by Morota et al. (J Neurosurg Pediatr 19:428-439, 2017). Additional inclusion criteria included asymptomatic status at presentation, age >3 years at follow-up, and neurological and urological evaluation at presentation and at last follow-up. Lipoma extent and conus level were recorded. Outcome measures were the need for untethering surgery and neuro-urological status at last follow-up. Urological outcomes were defined by continence and efficacy of bladder emptying. RESULTS Twenty-six children were included (median age 8.7 years). Conus level was low (at or below L2) in 92%. Nine required untethering surgery: 5 prophylactic, 4 because of clinical deterioration. Twenty-five children were continent at last follow-up, one had stress incontinence, and none required catheterisation. One had persisting ankle weakness after surgery requiring orthotic support. CONCLUSIONS In LSL of the conus, visualisation of the conus on MRI is associated with good urological and motor outcomes. The integrity of the conus appears to be a more important prognostic factor than anatomical level. An observational approach to this group of LSL patients does not appear to compromise outcomes. These findings support a selective approach to untethering surgery.
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Affiliation(s)
- Dominic N P Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | - Jochem Spoor
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Department of Paediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martje Schotman
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Department of Urology, Haga Hospitals, The Hague, The Netherlands
| | - Susan Maestri
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Claudia L Craven
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Divyesh Desai
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, UK
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26
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Valentini LG, Babini M, Cordella R, Beretta E, Destro F, Murabito P, Caldiroli D, Devigili G, Selvaggio G. Early de-tethering: analysis of urological and clinical consequences in a series of 40 children. Childs Nerv Syst 2021; 37:941-949. [PMID: 32728933 DOI: 10.1007/s00381-020-04838-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/23/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Early de-tethering procedures are performed on spinal dysraphisms to prevent neuro-urological deterioration caused by growth. Partial lipoma removal may cause delayed deterioration by re-tethering, while complete removal may increase the risk of postoperative worsening. The present study evaluates the risk of postoperative deterioration and the protective potential of intraoperative neurophysiological monitoring (IOM), with a special reference to the conus lipomas treated with the radical approach. METHODS Forty toddlers (< 24 months) underwent complete perioperative neurological and urological assessment, including urodynamic study (UDS). The dysraphisms were subgrouped according to Pang's classification. IOM was applied in all patients: transcranial motor evoked potentials (tMep) combined with mapping were recorded in all cases while bulbocavernosus reflex (BCR) was evaluable just in 7 cases. RESULTS At preoperative evaluation, 11 children already had UDS impairment and 2 had motor disturbances before neurosurgery. At 1-month follow-up, preoperative motor disturbances were stable, 7/11 UDS alterations normalized, and the remaining 4 were stable. At 6-month follow-up, all motor deficits and 8/11 preoperative UDS alterations had improved. Unfortunately, 7 children with previously normal UDS experienced a new impairment after surgery: 2/7 normalized while 5/7 did not recover. This postoperative permanent urodynamic impairment occurred in 4 chaotic lipoma (CLchaos) and in one terminal myelocystocele (TMC) that means a surgical deterioration rate of 22% for the high risk cases. CONCLUSIONS This small highly selected series confirms that early de-tethering may stop or revert the spontaneous neuro-urological deterioration: in fact, preoperative UDS impairment was frequent (27.5%) and improved in all the low surgical risk cases (limited dorsal myeloschisis, filar, transitional and dorsal lipomas). On the contrary, in CLchaos and TMC, early de-tethering was unable to revert preoperative UDS impairment, and radical surgery carried a high risk of new neuro-urological deterioration directly caused by the operation. In our experience, IOM had a protective role for motor functions, while it was less effective for the neuro-urological ones, probably due to the anesthesiology regimens applied. In conclusion, among the dysraphisms, CLchoas proved to be the worst enemy that often camouflages at MRI. Affording it without all possible IOM weapons carries a high risk to harm the patient.
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Affiliation(s)
- Laura Grazia Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "Carlo Besta", 20133, Milan, Italy.
| | - Micol Babini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "Carlo Besta", 20133, Milan, Italy
| | - Roberto Cordella
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "Carlo Besta", 20133, Milan, Italy
| | - Elena Beretta
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "Carlo Besta", 20133, Milan, Italy
| | - Francesca Destro
- Pediatric Surgery Unit, Children's Hospital "Vittore Buzzi", Milan, Italy
| | - Paolo Murabito
- Anesthesiology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Dario Caldiroli
- Anesthesiology Unit, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Grazia Devigili
- Department of Neurology, Fondazione IRCCS Istituto Neurologico "Carlo Besta", Milan, Italy
| | - Giorgio Selvaggio
- Pediatric Surgery Unit, Children's Hospital "Vittore Buzzi", Milan, Italy
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Moussa M, Papatsoris AG, Chakra MA, Fares Y, Dabboucy B, Dellis A. Perspectives on urological care in spina bifida patients. Intractable Rare Dis Res 2021; 10:1-10. [PMID: 33614369 PMCID: PMC7882087 DOI: 10.5582/irdr.2020.03077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/04/2020] [Accepted: 12/12/2020] [Indexed: 02/05/2023] Open
Abstract
Spina bifida (SB) is a neurogenetic disorder with a complex etiology that involves genetic and environmental factors. SB can occur in two major forms of open SB or SB aperta and closed SB or SB occulta. Myelomeningocele (MMC), the most common neural tube defects (NTDs), occurs in approximately 1 in 1,000 births. Considering non-genetic factors, diminished folate status is the best-known factor influencing NTD risk. The methylenetetrahydrofolate reductase (MTHFR) gene has been implicated as a risk factor for NTDs. The primary disorder in the pathogenesis of MMC is failed neural tube closure in the embryonic spinal region. The clinical manifestation of SB depends on clinical type and severity. SB can be detected in the second trimester using ultrasound which will reveal specific cranial signs. The management of MMC traditionally involves surgery within 48 h of birth. Prenatal repair of MMC is recommended for fetuses who meet maternal and fetal Management of Myelomeningocele Study (MOMS) specified criteria. Urological manifestations of SB include urinary incontinence, urolithiasis, sexual dysfunction, renal dysfunction, and urinary tract infection. Renal failure is among the most severe complications of SB. The most important role of the urologist is the management of neurogenic bladder. Medical management with clean intermittent catheterization and anticholinergic treatment is generally considered the gold standard of therapy. However, when this therapy fails surgical reconstruction become the only remaining option. This review will summarize the pathogenesis, risk factors, genetic contribution, diagnostic test, and management of SB. Lastly, the urologic outcomes and therapies are reviewed.
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Affiliation(s)
- Mohamad Moussa
- Urology Department, Zahraa Hospital, University Medical Center, Lebanese University, Beirut, Lebanon
| | - Athanasios G. Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Mohamad Abou Chakra
- Department of Urology, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Youssef Fares
- Department of Neurosurgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Baraa Dabboucy
- Department of Neurosurgery, Faculty of Medicine, Lebanese University, Beirut, Lebanon
| | - Athanasios Dellis
- Department of Urology/General Surgery, Areteion Hospital, Athens, Greece
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MRI evaluation of fetal tethered-cord syndrome: correlation with ultrasound findings and clinical follow-up after birth. Clin Radiol 2021; 76:314.e1-314.e8. [PMID: 33485624 DOI: 10.1016/j.crad.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 12/17/2020] [Indexed: 11/22/2022]
Abstract
AIM The study aimed to describe the features of magnetic resonance imaging (MRI) in fetuses with tethered-cord syndrome (TCS) or lower spinal cord (LSC) and to analyse the clinical outcomes and complications during follow-up. MATERIALS AND METHODS This is a retrospective study of fetuses diagnosed with TCS or LSC using MRI from January 2015 to August 2019. The average gestational week (GW) at MRI examination was 25.46 ± 4.73 GW (range: 21-39 GW). MRI was used1 to identify the anatomical landmarks of the spine2; to measure the width of the conus medullaris and record the ending position of the LSC3; and to analyse other neurological deformities. The diagnostic results between MRI and ultrasonography (US) were compared. RESULTS A total of 38 fetuses with suspected intracranial or spinal lesions on US or MRI were included. Among all fetuses, 17 fetuses were diagnosed with LSC or TCS without associated anomalies. Twenty-one fetuses had complications of central nervous system (CNS) anomalies, one fetus also had a diagram hernia, and one fetus had an inverse foot. MRI provided more diagnoses than US in nine fetuses. Two cases of diastematomyelia detected on MRI were missed on US. The capability of MRI was comparable with that of US in terms of displaying spina bifida. CONCLUSION In the present study, fetal MRI showed better performance than US for depicting TCS and related CNS abnormalities. MRI provided clinicians with additional information in terms of prenatal counselling and management.
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Morizawa Y, Satoh H, Sato A, Iwasa S, Aoki Y. [TETHERED CORD SYNDROME IN CHILDREN WITH DAYTIME INCONTINENCE]. Nihon Hinyokika Gakkai Zasshi 2021; 112:168-172. [PMID: 36261345 DOI: 10.5980/jpnjurol.112.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
(Introduction) In tethered cord syndrome, the lower end of the spinal cord is moored to the caudal tissue, causing various neuropathies. Bladder dysfunction often appears early. We herein evaluated children with daytime urinary incontinence in whom tethered cord syndrome was eventually diagnosed. (Method) Eighteen children (9 males and 9 females) with daytime urinary incontinence were enrolled between March 2011 and October 2017. The causes of their urinary incontinence were investigated using spinal MRI and changes in clinical symptoms before and after untethering surgery. (Results) The average age at the first visit was 6.3 years (range: 4-9 years). Urodynamic testing and a voiding cystourethrogram (VCUG) were performed in all cases of refractory daytime incontinence, and all patients with abnormal findings on either test underwent spinal MRI. The diagnosis based on spinal MRI findings was filum lipoma in eight, occult tethered cord syndrome in four, low set conus in four, conus lipoma in one, and sacral meningeal cyst in one, patient. The average observation period after untethering surgery was 66.3 months (range: 22-116 months). All the patients achieved a cure postoperatively. Four patients were treated for nocturnal enuresis by oral medication, and three patients required urological management via clean, intermittent catheterization. (Conclusions) When treating children with daytime continence, one should consider the possibility of tethered cord syndrome, the diagnosis of which can be aided by urodynamic assessment of bladder function.
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Affiliation(s)
- Yosuke Morizawa
- Department of Urology, Tokyo Metropolitan Children's Medical Center
| | - Hiroyuki Satoh
- Department of Urology, Tokyo Metropolitan Children's Medical Center
| | - Atsuko Sato
- Department of Urology, Tokyo Metropolitan Children's Medical Center
| | - Shun Iwasa
- Department of Urology, Tokyo Metropolitan Children's Medical Center
- Department of Urology, Keio University School of Medicine
| | - Yujiro Aoki
- Department of Urology, Tokyo Metropolitan Children's Medical Center
- Department of Nephrology, School of Medicine, Faculty of Medicine, Toho University
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Panagopoulos D, Karydakis P, Themistocleous M, Markogiannakis G. The 100 most cited papers centered on tethered cord syndrome. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Occult tethered cord syndrome in the canine: Microsurgical resection of the filum terminale. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Wide P, Duchén K, Mattsson S, Glad Mattsson G. Four-hour voiding observation with provocation test reveals significant abnormalities of bladder function in newborns with spinal dysraphism. J Pediatr Urol 2020; 16:491.e1-491.e7. [PMID: 32782223 DOI: 10.1016/j.jpurol.2020.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Four-hour voiding observation with provocation test (VOP) using a scale, a damp detector and ultrasound for determination of residuals, is an easily performed non-invasive method for the evaluation of bladder function in newborns. Neonatal bladder function evaluated with VOP has been described for healthy newborns (HN) but not for children with spinal dysraphism (SD), for whom early bladder evaluation is essential for decisions regarding Clean Intermittent Catheterization and follow-up. The aim of the present study was to describe voiding observation with provocation test in newborns with spinal dysraphism and compare with corresponding data for healthy newborns. METHODS AND MATERIALS At a tertiary hospital, a 4 h voiding observation with provocation (VOP) was performed in 50 neonates (22 girls, 28 boys) with spinal dysraphism (37 open SD, 13 closed SD) consecutively evaluated for possible neurogenic bladder-sphincter dysfunction (1998-2019). All newborns with open SD and 4/13 with closed SD had been through postnatal neurosurgery before the test. Mean age was 10 days. Voiding observation was performed during 4 h with visual observation the fourth hour recording behavior and urinary flow (e.g. stream, dribbling). Finally, bladder provocations (e.g. suprapubic compression) were performed, and any leakage was noted. Findings were compared to those of 50 healthy newborns (HN) earlier published (Gladh et al., 2002). There were no significant differences in background data such as gender, age or diuresis between newborns with SD and HN. RESULTS AND DISCUSSION Voiding observation with provocation test of children with SD revealed significant differences compared to HN see summary table. Some children with SD had frequent small voids/leakages and low bladder volumes while three had no voiding and high volumes. Leakage during bladder provocation test and not voiding with a stream was not seen in HN but were common in newborns with SD (69% resp. 74%) (p < 0.01). A child with these findings should thus be investigated further. Identifying children needing Clean Intermittent Catheterization is important as well as being able to postpone or refrain from invasive urodynamic studies if not strongly indicated. VOP may give valuable information for these judgements. CONCLUSION Newborns with spinal dysraphism differ from healthy newborns in many aspects of bladder function. Bladder function varies between newborns with closed and open spinal dysraphism. Many newborns with spinal dysraphism leak at bladder provocation and void without a stream but healthy newborns do not. Early determination of post-void residuals is mandatory in children with spinal dysraphism and non-invasive VOP gives this information in a standardized way, also adding information on frequency, voiding with a stream and leakage at provocation.
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Affiliation(s)
- Peter Wide
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, SE-581 83, Linköping, Sweden.
| | - Karel Duchén
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, SE-581 83, Linköping, Sweden.
| | - Sven Mattsson
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, SE-581 83, Linköping, Sweden.
| | - Gunilla Glad Mattsson
- Department of Biomedical and Clinical Sciences and Department of Pediatrics, Linköping University, SE-581 83, Linköping, Sweden.
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Son HS, Kim JH. Urological presentations of adult primary tethered cord syndrome. Neurourol Urodyn 2019; 39:633-641. [PMID: 31782978 DOI: 10.1002/nau.24231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/04/2019] [Indexed: 11/11/2022]
Abstract
AIMS To investigate the urological presentations of patients initially diagnosed with closed spinal dysraphism in adulthood: adult primary tethered cord syndrome (ApTCS). METHODS Patients with ApTCS who underwent subsequent untethering were studied. Urological presentations were evaluated grouped by symptom onset period of either after (group 1) or before (group 2) the completion of physical growth. RESULTS Of the 43 patients, median age at diagnosis and initial untethering was 35.5 (18.4-67.2) years. At diagnosis, 90.7% (39/43) had urological symptoms and 18.6% (8/43) initially consulted a urologist without noticeable neurological symptoms. Enuresis was observed in 16.3% (7/43) and common among patients without significant neurological symptoms (62.5%, 5/8). Urgency urinary incontinence and frequency prevailed in group 1. Stress urinary incontinence and straining to void prevailed in group 2. Among 26 patients with pre- and post-operative urodynamics, detrusor overactivity predominated in group 1 and acontractile detrusor predominated in group 2. Glomerular filtration rate ≥90 mL/min/1.73m2 was noted in 86.0% (37/43) and 84.9% (73/86) of renal units were morphometrically intact. More patients in group 2 (93.3%) relied on assisted emptying than in group 1 (53.6%). CONCLUSIONS In ApTCS, enuresis was prevalent among patients without noticeable neurological symptoms. Over 80% in both groups had favorable renal function. Bladder conditions were different based on symptom onset period. Significantly more patients whose symptoms developed before completion of growth relied on assisted emptying. Proper discerning might be crucial in ApTCS which has a potential of misdiagnosis even in the modern developed era.
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Affiliation(s)
- Hee Seo Son
- Department of Urology and Urological Science Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jang Hwan Kim
- Department of Urology and Urological Science Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Bhimani AD, Selner AN, Patel JB, Hobbs JG, Esfahani DR, Behbahani M, Zayyad Z, Nikas D, Mehta AI. Pediatric tethered cord release: an epidemiological and postoperative complication analysis. JOURNAL OF SPINE SURGERY 2019; 5:337-350. [PMID: 31663045 DOI: 10.21037/jss.2019.09.02] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background Tethered cord release (TCR) is a common procedure in pediatric neurosurgery. Despite a reputation for being relatively safe, the risk factors for postoperative complications are poorly understood. Methods In this study, the American College of Surgeons-National Surgical Quality Improvement Program Pediatric Database (ACS-NSQIP-P) was reviewed to identify the demographics, risk factors, and 30-day postoperative complications for tethered cord release using univariate and multivariate analysis. A detailed analysis of reasons for readmission and reoperation was also performed. Results Three thousand and six hundred eighty-two pediatric patients were studied. Males undergoing TCR were younger (5.6 vs. 6.1 years) and had a higher rate of pre-operative comorbidities but lower 30-day complication rate versus females. Patients who later developed complications were more likely to require a microscope intraoperatively, had longer operative times, and worse preoperative American Society of Anesthesiologists (ASA) class. Conclusions Despite being a relatively safe procedure, TCR in the pediatric population carries a finite risk of complications. In this large, international database study, males were found to have a greater number of risk factors prior to TCR, while females exhibit a higher risk of developing postoperative complications. This paper provides a large sample size of multi institutional pediatric patients undergoing TCR and may serve as a contemporary "snapshot" for future studies.
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Affiliation(s)
- Abhiraj D Bhimani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.,Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ashley N Selner
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jay B Patel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Jonathan G Hobbs
- Section of Neurosurgery, The University of Chicago, Chicago, IL, USA
| | - Darian R Esfahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Mandana Behbahani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Zaid Zayyad
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Demetrios Nikas
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Shields LBE, Mutchnick IS, Peppas DS, Rosenberg E. Importance of Physical Examination and Imaging in the Detection of Tethered Cord Syndrome. Glob Pediatr Health 2019; 6:2333794X19851419. [PMID: 31218244 PMCID: PMC6563391 DOI: 10.1177/2333794x19851419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 01/15/2023] Open
Abstract
Tethered cord syndrome (TCS) is a type of occult spinal dysraphism that may lead to permanent neurologic and orthopedic deficits. Infants with TCS may have lumbosacral cutaneous malformations (LsCMs). We studied 67 infants referred to a single pediatric urology practice for a urological concern unrelated to occult spinal dysraphism with no prior diagnosis of LsCM between March 1, 2015 and September 30, 2018. Each infant underwent a spinal ultrasound. If an abnormality was detected, they were referred to a pediatric neurosurgeon. The most common cutaneous manifestations were duplicated or bifurcated (46%) gluteal folds and gluteal asymmetry (16%). Fourteen (21%) of the 67 patients had an abnormal spinal ultrasound; 5 of the 14 infants underwent a lumbar magnetic resonance imaging. One infant had urodynamics studies and a tethered cord release. Pediatricians should be familiar with TCS and perform lumbar physical examinations for LsCMs suggestive of TCS to ensure prompt diagnosis and management and avoid potentially devastating complications.
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Rensing AJ, Szymanski KM, Dunn S, King S, Cain MP, Whittam BM. Pediatric sacral nerve stimulator explanation due to complications or cure: a survival analysis. J Pediatr Urol 2019; 15:39.e1-39.e6. [PMID: 30473473 DOI: 10.1016/j.jpurol.2018.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/31/2018] [Accepted: 10/12/2018] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Historically, there have been few treatment options for children with severe refractory bladder and bowel dysfunction (BBD). Sacral neuromodulation (SNM) continues to show promising results in this challenging pediatric population with recalcitrant lower urinary tract symptoms. At the authors institution, they have begun offering explantation to those with persistent improvement after >6 months of having device turned off. The authors hypothesized that (1) SNM explantation for cure increases with extended follow-up and (2) those explanted for cure would have improved symptoms and quality of life when compared to those explanted for complication. MATERIALS & METHODS The authors retrospectively reviewed all consecutive patients aged <18 years who underwent SNM placements at their institution (2012-2017). They excluded those without the second stage procedure. Reasons for device explantation were categorized as cure (resolution of symptoms with the device turned off for at least 6 months) or a complication (e.g. infection, need for magnetic resonance imaging, or pain). Non-parametric tests and survival analysis were used for analysis to account for differential follow-up time. Of those explanted, surveys were electronically sent to assess BBD severity and overall quality of life. RESULTS Of 67 children who underwent a first stage procedure, 62 (92.5%) underwent a second stage procedure. 61 met inclusion criteria (68.9% female, 29.5% with previous filum section, median age at implantation 10.3 years). During follow-up (median 2.3 years), 12 patients (19.7%) had the SNM exchanged/revised because of lead fracture/breakage and return of urinary symptoms. To date, 50 patients remain with their SNM implanted, and 11 have been explanted. Adjusting for follow-up time, the risk of explantation was 6.5% at 2 years (2.2% for cure, 4.3% for complications) (Figure 1). Explantation increased to 24.5% at 3 years (16.5% for cure, 8.0% for complications) and 40.4% at 4 years (32.4% for cure, 8.0% for complications). Questionnaires were collected on patients after explant (median 2.2 years), with improvement in those explanted for cure compared to complication (Figure 2). DISCUSSION Sacral neuromodulation explantation for cure is a novel concept previously not described in the literature. Limitations of this study include the relatively small numbers and lack of objective data in the cohort that remains with SNM device implanted. CONCLUSION Sacral neuromodulation is a safe, viable option for the pediatric patient with refractory bladder dysfunction. Furthermore, SNM explantation for cure is an option with increasing likelihood after 2 years.
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Affiliation(s)
- A J Rensing
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - K M Szymanski
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - S Dunn
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - S King
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - M P Cain
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - B M Whittam
- Division of Pediatric Urology, Department of Urology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Peyronnet B, Brochard C, Jezequel M, Hascoet J, Alimi Q, Senal N, Carsin-Nicole B, Riffaud L, Le Reste PJ, Bonan I, Olivari-Philiponnet C, Siproudhis L, Kerdraon J, Game X, Manunta A. Comparison of neurogenic lower urinary tract dysfunctions in open versus closed spinal dysraphism: A prospective cross-sectional study of 318 patients. Neurourol Urodyn 2018; 37:2818-2826. [DOI: 10.1002/nau.23782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/09/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Benoit Peyronnet
- Service d'urologie; CHU Rennes; Rennes France
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Equipe thématique INPHY CIC 1414 et INSERM UMR 991; CHU Rennes; Rennes France
| | - Charlène Brochard
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Equipe thématique INPHY CIC 1414 et INSERM UMR 991; CHU Rennes; Rennes France
- Service de Gastro-Entérologie; CHU Rennes; Rennes France
| | | | - Juliette Hascoet
- Service d'urologie; CHU Rennes; Rennes France
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Equipe thématique INPHY CIC 1414 et INSERM UMR 991; CHU Rennes; Rennes France
| | - Quentin Alimi
- Service d'urologie; CHU Rennes; Rennes France
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Equipe thématique INPHY CIC 1414 et INSERM UMR 991; CHU Rennes; Rennes France
| | - Nelly Senal
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Service de Médecine Physique et Réadaptation; CHU Rennes; Rennes France
| | - Béatrice Carsin-Nicole
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Service de Neuro-Radiologie; CHU Rennes; Rennes France
| | - Laurent Riffaud
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Service de Neurochirurgie; CHU Rennes; Rennes France
| | - Pierre-Jean Le Reste
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Service de Neurochirurgie; CHU Rennes; Rennes France
| | - Isabelle Bonan
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Service de Médecine Physique et Réadaptation; CHU Rennes; Rennes France
| | - Camille Olivari-Philiponnet
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Service de Médecine Physique et Réadaptation; CHU Rennes; Rennes France
| | - Laurent Siproudhis
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Equipe thématique INPHY CIC 1414 et INSERM UMR 991; CHU Rennes; Rennes France
- Service de Gastro-Entérologie; CHU Rennes; Rennes France
| | - Jacques Kerdraon
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Centre de rééducation de Kerpape; Ploemeur France
| | - Xavier Game
- Département d'Urologie; Transplantation Rénale et Andrologie; CHU Rangueil; Toulouse France
| | - Andrea Manunta
- Service d'urologie; CHU Rennes; Rennes France
- Centre de référence spina bifida; CHU Rennes; Rennes France
- Equipe thématique INPHY CIC 1414 et INSERM UMR 991; CHU Rennes; Rennes France
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Clinical Outcomes of Primary and Revision Untethering Surgery in Patients with Tethered Cord Syndrome and Spinal Bifida. World Neurosurg 2018; 116:e66-e70. [PMID: 29649647 DOI: 10.1016/j.wneu.2018.03.221] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 11/24/2022]
Abstract
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.
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