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Findlay MC, Tenhoeve S, Terry SA, Iyer RR, Brockmeyer DL, Kelly MP, Kestle JRW, Gonda D, Ravindra VM. Disparities in indications and outcomes reporting for pediatric tethered cord surgery: The need for a standardized outcome assessment tool. Childs Nerv Syst 2024; 40:1111-1120. [PMID: 38072858 PMCID: PMC10972940 DOI: 10.1007/s00381-023-06246-y] [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: 10/30/2023] [Accepted: 11/29/2023] [Indexed: 03/28/2024]
Abstract
PURPOSE Tethered cord syndrome (TCS) is characterized by abnormal attachment of the spinal cord neural elements to surrounding tissues. The most common symptoms include pain, motor or sensory dysfunction, and urologic deficits. Although TCS is common in children, there is a significant heterogeneity in outcomes reporting. We systematically reviewed surgical indications and postoperative outcomes to assess the need for a grading/classification system. METHODS PubMed and EMBASE searches identified pediatric TCS literature published between 1950 and 2023. Studies reporting surgical interventions, ≥ 6-month follow-up, and ≥ 5 patients were included. RESULTS Fifty-five studies representing 3798 patients were included. The most commonly reported non-urologic symptoms were nonspecific lower-extremity motor disturbances (36.4% of studies), lower-extremity/back pain (32.7%), nonspecific lower-extremity sensory disturbances (29.1%), gait abnormalities (29.1%), and nonspecific bowel dysfunction/fecal incontinence (25.5%). Urologic symptoms were most commonly reported as nonspecific complaints (40.0%). After detethering surgery, retethering was the most widely reported non-urologic outcome (40.0%), followed by other nonspecific findings: motor deficits (32.7%), lower-extremity/back/perianal pain (18.2%), gait/ambulation function (18.2%), sensory deficits (12.7%), and bowel deficits/fecal incontinence (12.7%). Commonly reported urologic outcomes included nonspecific bladder/urinary deficits (27.3%), bladder capacity (20.0%), bladder compliance (18.2%), urinary incontinence/enuresis/neurogenic bladder (18.2%), and nonspecific urodynamics/urodynamics score change (16.4%). CONCLUSION TCS surgical literature is highly variable regarding surgical indications and reporting of postsurgical outcomes. The lack of common data elements and consistent quantitative measures inhibits higher-level analysis. The development and validation of a standardized outcomes measurement tool-ideally encompassing both patient-reported outcome and objective measures-would significantly benefit future TCS research and surgical management.
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Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Samuel Tenhoeve
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Skyler A Terry
- College of Social and Behavioral Sciences, University of Utah, Salt Lake City, UT, USA
| | - Rajiv R Iyer
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Douglas L Brockmeyer
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Michael P Kelly
- Division of Pediatric Orthopedics, Rady Children's Hospital, San Diego, CA, USA
| | - John R W Kestle
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - David Gonda
- Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
- Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
- Department of Neurological Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
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Allografts for Skin Closure during In Utero Spina Bifida Repair in a Sheep Model. J Clin Med 2021; 10:jcm10214928. [PMID: 34768448 PMCID: PMC8584988 DOI: 10.3390/jcm10214928] [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: 09/16/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives: Use of off-label tissue graft materials, such as acellular dermal matrix (ADM), for in utero repair of severe spina bifida (SB), where primary skin layer closure is not possible, is associated with poor neurological outcomes. The cryopreserved human umbilical cord (HUC) patch has regenerative, anti-inflammatory, and anti-scarring properties, and provides watertight SB repair. We tested the hypothesis that the HUC is a superior skin patch to ADM for reducing inflammation at the repair site and preserving spinal cord function. Methods: In timed-pregnant ewes with twins, on gestational day (GD) 75, spina bifida was created without a myelotomy (functional model). On GD 95, repair was performed using HUC vs. ADM patches (randomly assigned) by suturing them to the skin edges. Additionally, full thickness skin closure as a primary skin closure (PSC) served as a positive control. Delivery was performed on GD 140, followed by blinded to treatment neurological assessments of the lambs using the Texas Spinal Cord Injury Scale (TSCIS) for gait, proprioception, and nociception. Lambs without spina bifida were used as controls (CTL). Ex vivo magnetic resonance imaging of spines at the repair site were performed, followed by quantitative pathological assessments. Histological assessments (blinded) included Masson’s trichrome, and immunofluorescence for myeloperoxidase (MPO; neutrophils) and for reactive astrocytes (inflammation) by co-staining vimentin and GFAP. Results: The combined hind limbs’ TSCIS was significantly higher in the HUC group than in ADM and PSC groups, p = 0.007. Both ADM and PSC groups exhibited loss of proprioception and mild to moderate ataxia compared to controls. MRI showed increased pathological findings in the PSC group when compared to the HUC group, p = 0.045. Histologically, the meningeal layer was thickened (inflammation) by 2–3 fold in ADM and PSC groups when compared to HUC and CTL groups, p = 0.01. There was lower MPO positive cells in the HUC group than in the ADM group, p = 0.018. Posterior column astrocyte activation was increased in ADM and PSC lambs compared to HUC lambs, p = 0.03. Conclusion: The HUC as a skin patch for in utero spina bifida repair preserves spinal cord function by reducing underlying inflammation when compared to ADM.
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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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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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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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Tuite GF, Thompson DNP, Austin PF, Bauer SB. Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society. Neurourol Urodyn 2017; 37:890-903. [PMID: 28792087 DOI: 10.1002/nau.23382] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/01/2017] [Indexed: 01/05/2023]
Abstract
AIMS As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Children's Continence Society (ICCS) recommendations for diagnosis and treatment of OSD. METHODS Guidelines were formulated based on analysis of pertinent literature and consensus among authors. This document was vetted by the multidisciplinary members of the ICCS via its website before submission for peer review publication. RESULTS The more frequent diagnosis of OSD is associated with increased operative intervention. Spinal cord untethering (SCU) has a highly variable risk profile, largely dependent on the specific form of OSD. Progressive neurological deterioration attributed to "tethered cord" may occur, with or without surgery, in selected forms of OSD whereas other cohorts do well. CONCLUSION Infants with classic cutaneous markers of OSD, with progressive neurologic, skeletal, and/or urologic findings, present no diagnostic or therapeutic dilemma: they routinely undergo MRI and SCU. Conversely, in asymptomatic patients or those with fixed, minor abnormalities, the risk profile of these OSD cohorts should be carefully considered before SCU is performed. Irrespective of whether or not SCU is performed, patients at risk for progression should be followed carefully throughout childhood and adolescence by a multidisciplinary team.
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Affiliation(s)
- Gerald F Tuite
- Institute of Brain Protection Science, Division of Pediatric Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Dominic N P Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Paul F Austin
- Department Surgery, Division of Urology, Texas Children's Hospital & Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Stuart B Bauer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
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Dulfer SE, Drost G, Lange F, Journee HL, Wapstra FH, Hoving EW. Long-term evaluation of intraoperative neurophysiological monitoring-assisted tethered cord surgery. Childs Nerv Syst 2017; 33:1985-1995. [PMID: 28676974 PMCID: PMC5644688 DOI: 10.1007/s00381-017-3478-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/05/2017] [Indexed: 12/01/2022]
Abstract
PURPOSE Patients with tethered spinal cord have been investigated for short-term effects after tethered spinal cord surgery in the past. However, little is known about the long-term effects in this patient group. In this retrospective, longitudinal, observational study, a patient sample of a previous report of 65 patients was reassessed to observe the long-term effects of intraoperative neurophysiological monitoring-assisted tethered cord surgery. METHODS With the use of patient charts and a survey, patients were scored on four domains: (1) neurological deficits, (2) urological deficits, (3) pain symptoms, and (4) orthopedic deficits. Measurements were performed at four moments in time: (1) preoperatively, (2) postoperatively, (3) follow-up 1 (4.6 years), and (4) follow-up 2 (11.2 years). Besides this, a subgroup analysis and a quality of life questionnaire were performed. RESULTS When observing the symptom domains in the long-term, the pain domain appeared to improve most postoperatively after which it remained stable over time. The neurological and urological domains showed a stable, slightly decreasing trend in the long-term follow-up. The orthopedic domain showed a significant increase of the number of patients with scoliosis during the long-term follow-up. CONCLUSIONS Lasting effects of stability in the neurological, urological, and pain domains were observed. Close monitoring during follow-up might contribute to early recognition of progressive scoliosis, in spite of detethering, in a risk group defined by females who underwent tethered cord surgery at or under the age of 12 years old with either lipomyelomeningocele, split cord malformation, or myelomeningocele. Detethering does not appear to protect these patients against progressive scoliosis.
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Affiliation(s)
- S. E. Dulfer
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - G. Drost
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands ,Department of Neurology, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - F. Lange
- Department of Neurology, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - H. L. Journee
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - F. H. Wapstra
- Department of Orthopedics, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
| | - E. W. Hoving
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands
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Maurya VP, Rajappa M, Wadwekar V, Narayan SK, Barathi D, Madhugiri VS. Tethered Cord Syndrome-A Study of the Short-Term Effects of Surgical Detethering on Markers of Neuronal Injury and Electrophysiologic Parameters. World Neurosurg 2016; 94:239-247. [PMID: 27422680 DOI: 10.1016/j.wneu.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 07/02/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Several studies have assessed clinical and radiologic outcomes after detethering of the cord for tethered cord syndrome (TCS). However, no data regarding the impact of detethering on the metabolism or electrophysiologic functioning of the cord are available. The aim of this study was to assess the changes in the cerebrospinal fluid (CSF) levels of markers of neuronal injury and alterations in the electrophysiologic functioning of the spinal cord after detethering. METHODS This prospective study included patients with congenital TCS. Patients underwent clinical assessment, magnetic resonance imaging, somatosensory evoked potentials (SSEP) study, and CSF biochemical analysis (to estimate lactate, glial fibrillary acidic protein, and S100B levels), before and 3 months after surgery. Clinical and radiologic outcomes were assessed. We studied changes in biochemical and electrophysiologic parameters before and after detethering as surrogate markers for the effects of this intervention. RESULTS Twenty-one patients were recruited over 2 years. Detethering led to clinical improvement in 75% of patients with motor deficits, 60% of patients with bladder symptoms, and 50% of patients with gait problems. At 3 months follow-up, 43% (median) of the preoperative vertical tethering was found to be corrected. There was significant reduction in CSF lactate, glial fibrillary acidic protein, and S100B levels as well as a significant decrease in the latencies of the SSEP waves 3 months after surgery. CONCLUSIONS Surgical detethering led to a reduction in the CSF levels of the markers of anaerobic metabolism and neuronal injury. There was also a reduction in the latencies of the SSEP waves, indicating better electrophysiologic functioning of the cord.
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Affiliation(s)
- Ved Prakash Maurya
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Medha Rajappa
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Vaibhav Wadwekar
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Sunil K Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Deepak Barathi
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Venkatesh S Madhugiri
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India.
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Papanna R, Mann LK, Snowise S, Morales Y, Prabhu SP, Tseng SCG, Grill R, Fletcher S, Moise KJ. Neurological Outcomes after Human Umbilical Cord Patch for In Utero Spina Bifida Repair in a Sheep Model. AJP Rep 2016; 6:e309-17. [PMID: 27621952 PMCID: PMC5017885 DOI: 10.1055/s-0036-1592316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The objective of our study was to test the hypothesis that in utero repair of surgically created spina bifida in a sheep model using cryopreserved human umbilical cord (HUC) patch improves neurological outcome. METHODS Spina bifida with myelotomy was surgically created in timed pregnant ewes at gestational day (GD) 75. The fetuses were randomly assigned to unrepaired versus HUC and treated at GD 95 and then delivered at GD 140. Neurological evaluation was performed using the Texas Spinal Cord Injury Scale (TSCIS), bladder control using ultrasound, and the hindbrain herniation. RESULTS Three lambs without the spina bifida creation served as controls. There were four lambs with spina bifida: two were unrepaired and two underwent HUC repair. The control lambs had normal function. Both unrepaired lambs had nonhealed skin lesions with leakage of cerebrospinal fluid, a 0/20 TSCIS score, no bladder control, and the hindbrain herniation. In contrast, both HUC lambs had a completely healed skin defect and survived to day 2 of life, a 3/20 and 4/20 TSCIS score (nociception), partial bladder control, and normal hindbrain anatomy. CONCLUSIONS Cryopreserved HUC patch appears to improve survival and neurological outcome in this severe form of the ovine model of spina bifida.
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Affiliation(s)
- Ramesha Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Lovepreet K Mann
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Saul Snowise
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Yisel Morales
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
| | - Sanjay P Prabhu
- Department of Radiology, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Scheffer C G Tseng
- The Ocular Surface Center, Miami, Florida; TissueTech, Inc., Miami, Florida
| | - Raymond Grill
- Department of Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, Mississippi
| | - Stephen Fletcher
- Division of Pediatric Neurosurgery, The Department of Pediatrics, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School, Houston, Texas; Department of Pediatric Surgery, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School, Houston, Texas
| | - Kenneth J Moise
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Medicine, UTHealth, The University of Texas Health Science at Houston, McGovern Medical School and the Fetal Center at Children's Memorial Hermann Hospital, Houston, Texas
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Role of Endoscopic Third Ventriculostomy in the Management of Myelomeningocele-Related Hydrocephalus: A Retrospective Study in a Single French Institution. World Neurosurg 2016; 87:484-93. [DOI: 10.1016/j.wneu.2015.07.071] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/20/2022]
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Papanna R, Moise KJ, Mann LK, Fletcher S, Schniederjan R, Bhattacharjee MB, Stewart RJ, Kaur S, Prabhu SP, Tseng SCG. Cryopreserved human umbilical cord patch for in-utero spina bifida repair. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:168-176. [PMID: 26489897 DOI: 10.1002/uog.15790] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/08/2015] [Accepted: 10/09/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To identify a patch system to repair surgically created spina bifida in a sheep model for its efficacy in healing the skin defect, protecting the underlying spinal cord and reducing the Chiari II malformation. METHODS Spina bifida was created surgically in 16 fetuses from eight timed-pregnant sheep at gestational age of 75 days. Two fetuses did not survive the procedure. Repeat hysterotomy was performed at 95 days' gestation to cover the defect with either biocellulose film with underwater adhesive (BCF-adhesive) (n = 7) or human umbilical cord with suture (HUC-suture) (n = 7). Three fetuses without formation of the defect served as reference controls. The skin healing was examined by direct visualization after a planned Cesarean section at term, followed by histological analysis using hematoxylin and eosin and Masson's trichrome stains. Mid-sagittal sections of the fetal cranium and upper cervical spine were analyzed by a pediatric neuroradiologist who was blinded to the type of patch received. RESULTS Three fetuses that received the BCF-adhesive and six fetuses that received the HUC-suture survived to term for final analysis. As a result of dislodgment of the BCF-adhesive, all spina bifida defects repaired using BCF-adhesive were not healed and showed exposed spinal cord with leakage of cerebrospinal fluid. In contrast, all spinal defects repaired by HUC-suture were healed with complete regrowth of epidermal, dermal and subdermal tissue components, with no exposed spinal cord. The maximal skin wound width was 21 ± 3.6 mm in the BCF-adhesive group but 3 ± 0.8 mm in the HUC-suture group (P < 0.001). The spinal cord area (P = 0.001) and the number of anterior horn cells (P = 0.03) was preserved to a greater degree in the HUC-suture group than in the BCF-adhesive group, whilst psammoma bodies, signifying neuronal degeneration, were only observed in the BCF-adhesive group. Anatomic changes, indicative of Chiari II malformation, were seen in all three fetuses of the BCF-adhesive group but in none of the HUC-suture group (P < 0.01). CONCLUSION Cryopreserved umbilical cord graft is a promising regenerative patch for intrauterine repair of spina bifida.
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Affiliation(s)
- R Papanna
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, UT Health School of Medicine, Houston, TX, USA
- Fetal Center, Houston, TX, USA
| | - K J Moise
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, UT Health School of Medicine, Houston, TX, USA
- Fetal Center, Houston, TX, USA
| | - L K Mann
- Department of Obstetrics, Gynecology and Reproductive Medicine, Division of Maternal-Fetal Medicine, UT Health School of Medicine, Houston, TX, USA
- Department of Pathology and Laboratory Services, UT Health School of Medicine, Houston, TX, USA
| | - S Fletcher
- Department of Pediatrics, Division of Pediatric Neurosurgery, UT Health School of Medicine, Houston, TX, USA
| | - R Schniederjan
- Department of Pediatric Surgery, UT Health School of Medicine, Houston, TX, USA
| | - M B Bhattacharjee
- Department of Pediatric Surgery, UT Health School of Medicine, Houston, TX, USA
| | - R J Stewart
- Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - S Kaur
- Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - S P Prabhu
- Department of Radiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - S C G Tseng
- Ocular Surface Center and TissueTech, Inc., Miami, FL, USA
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Spinal cord detethering in children with tethered cord syndrome and Chiari type 1 malformations. J Clin Neurosci 2015; 22:1749-52. [DOI: 10.1016/j.jocn.2015.05.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/22/2015] [Indexed: 02/07/2023]
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13
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Spinal cord detethering procedures in children: A 5year retrospective cohort study of the early post-operative course. J Clin Neurosci 2015; 22:838-42. [DOI: 10.1016/j.jocn.2014.11.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 11/12/2014] [Accepted: 11/22/2014] [Indexed: 11/19/2022]
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Murata Y, Kanaya K, Wada H, Wada K, Shiba M, Kato Y. Reduction of caudal traction force using dural sac opening rather than spinal cord detethering for tethered cord syndrome caused by lipomyelomeningocele: a case report. Spine J 2014; 14:e1-3. [PMID: 24613376 DOI: 10.1016/j.spinee.2014.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 02/27/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A few reports have addressed tethered cord syndrome. Detethering surgery has been performed in these cases because abnormal tension on the spinal cord causes neurologic and urologic symptoms. PURPOSE To discuss the surgical treatment of tethered cord syndrome with the belief that the tension on the cord can be decreased by shifting tethered cord to the dorsal side. STUDY DESIGN A patient with tethered cord syndrome was surgically treated by shifting the tethered cord to the dorsal side by harnessing the lumbar lordosis instead of detethering. METHODS We performed surgery to shift the tethered cord to the dorsal side by harnessing the lumbar lordosis to decrease the tension on the spinal cord. RESULTS The tethered cord that was pressed to the ventral side because of a lipoma was shifted dorsally by laminectomy and opening of the dural sac. Pain and numbness were alleviated immediately after surgery. CONCLUSIONS The method used in the present case, that is, shifting the tethered cord and lipoma to the dorsal side by harnessing the lumbar lordosis instead of detethering, is a viable treatment option for tethered cord syndrome.
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Affiliation(s)
- Yasuaki Murata
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku, Tokyo, Japan.
| | - Kohichi Kanaya
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku, Tokyo, Japan
| | - Hiroyoshi Wada
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku, Tokyo, Japan
| | - Keiji Wada
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku, Tokyo, Japan
| | - Masahiro Shiba
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku, Tokyo, Japan
| | - Yoshiharu Kato
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, 8-1 Kawadacho, Shinjuku, Tokyo, Japan
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Early identification of tethered cord syndrome: a clinical challenge. J Pediatr Health Care 2014; 28:e23-33. [PMID: 23932444 DOI: 10.1016/j.pedhc.2013.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 06/23/2013] [Accepted: 06/29/2013] [Indexed: 11/21/2022]
Abstract
Tethered cord syndrome (TCS) is a progressive clinical condition that arises from excessive spinal cord tension. The clinical signs and symptoms of TCS may be cutaneous, neurologic, musculoskeletal, genitourinary, and/or gastrointestinal. Patients also may be asymptomatic, which does not exclude the diagnosis of TCS. Although the exact etiology is unknown, early identification and lifelong surveillance or surgical treatment is an essential component of patient management. In this article we review the pathophysiology, various etiologies, clinical presentation, and long-term sequelae of TCS. This information will help pediatric nurse practitioners identify TCS early and anticipate the patient's needs and management requirements.
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Intraoperative neurophysiology in tethered cord surgery: techniques and results. Childs Nerv Syst 2013; 29:1611-24. [PMID: 24013331 DOI: 10.1007/s00381-013-2188-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 05/24/2013] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Intraoperative neurophysiologic monitoring (IOM) is nowadays extensively used to minimize neurological morbidity in tethered cord surgery. Our goal is to describe and discuss the standard IOM techniques used during these surgical procedures and to summarize our clinical experience using a multimodal IOM approach. MATERIAL AND METHODS Neurophysiological mapping of the conus-cauda is performed through direct stimulation of these structures and bilateral recording from segmental target muscles. While mapping identifies ambiguous neural structures, their functional integrity during surgery can be assessed by monitoring techniques only, such as somatosensory evoked potentials (SEPs), transcranial motor-evoked potentials (MEPs) from the limb muscles and anal sphincters, and the bulbocavernosus reflex (BCR). RESULTS Between 2002 and 2012, we performed 48 surgical procedures in 47 patients with a tethered cord secondary to a variety of spinal dysraphisms. The monitorability rate was 84 % for SEPs, 97 % for limb muscle MEPs, 74 % for the anal sphincter MEPs, and 59 % for the BCR. In all patients but one, SEP, MEP, and BCR remained stable during surgery. Postoperatively, two out of 47 patients presented a significant-though transient-neurological worsening. In six patients, an unexpected muscle response was evoked by stimulating tissue macroscopically considered as not functional. CONCLUSIONS Mapping techniques allow identifying and sparing functional neural tissue and vice versa to cut nonfunctional structures that may contribute to cord tethering. Monitoring techniques, MEP and BCR in particular, improve the reliability of intraoperative neurophysiology, though these may require a higher degree of neuromonitoring expertise. IOM minimizes neurological morbidity in tethered cord surgery.
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Romagna A, Suchorska B, Schwartz C, Tonn JC, Zausinger S. Detethering of a congenital tethered cord in adult patients: an outcome analysis. Acta Neurochir (Wien) 2013; 155:793-800. [PMID: 23471599 DOI: 10.1007/s00701-013-1652-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 02/08/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Tethered spinal cord syndrome (TCS) is characterized by attachment of the spinal cord down toward the tail end of the spine, comprising the danger of myelopathic symptoms. We retrospectively analyzed postoperative neurological outcome in adult patients with congenital TCS with special regard to the extent of resection of concomitant intraspinal lipomas. METHODS Medical records of 27 adult patients with congenital TCS (both with and without associated spinal lipomas) undergoing microsurgical detethering were systematically analyzed. Neurophysiological monitoring was available and feasible for all cases. Outcome parameters were preoperatively and postoperative neurological status; Wilcoxon rank test was used for statistical analysis. RESULTS In all patients, complete detethering was achieved. While urinary symptoms remained stable, all patients showed a non-significant tendency towards improvement of sensorimotor deficits. Both, patients with and without spinal lipoma experienced a significant postoperative amelioration of back pain. Patients with lipoma were found to suffer significantly less from radicular pain postoperatively (3/16). Furthermore, patients with a history of pain shorter than 1 year showed a significantly better chance for postoperative relief from back and radicular pain. The extent of lipoma resection had no significant impact on postoperative outcome. CONCLUSIONS Adult patients with symptomatic TCS profit from detethering, especially regarding relief of lower back and radicular pain. Complete removal of associated spinal lipomas does not seem to be mandatory for achieving a satisfying result.
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Khoshhal KI, Murshid WR, Elgamal EA, Salih MA. Tethered cord syndrome: A study of 35 patients. J Taibah Univ Med Sci 2012. [DOI: 10.1016/j.jtumed.2012.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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