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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 DOI: 10.1007/s00381-023-06246-y] [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: 10/30/2023] [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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Perera D, Craven CL, Thompson D. Lumbosacral lipoma in childhood, how strong is the evidence base? A systematic review. Childs Nerv Syst 2024; 40:715-728. [PMID: 37924337 DOI: 10.1007/s00381-023-06203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Conus region lumbosacral lipomas (LSLs) are highly heterogeneous in their morphology, clinical presentation, and outcome, with an incompletely understood natural history and often treacherous surgical anatomy. This systematic review aims to critically evaluate and assess the strength of the current LSL evidence base to guide management strategies. METHODS According to a systematic review following PRISMA guidelines, a search was conducted using the key term "lumbosacral lipoma" across MEDLINE (OVID), Embase, Cochrane Library, and PubMed databases from January 1951 to April 2021. All studies containing ten or more paediatric conus lipomas were included. Data heterogeneity and bias were assessed. RESULTS A total of 13 studies were included, containing 913 LSLs (predominantly transitional type-58.5%). Two-thirds (67.5%) of all patients (treated and non-treated) remained clinically stable and 17.6% deteriorated. Neuropathic bladder was present in 8.6% at final follow-up. Of patients managed surgically, near-total resection vs. subtotal resection deterioration-free survival rates were 77.2-98.4% and 10-67% respectively. 4.5% (0.0-27.3%) required re-do untethering surgery. Outcomes varied according to lipoma type. Most publications contained heterogeneous populations and used variable terminology. There was a lack of consistency in reported outcomes. CONCLUSION Amongst published series, there is wide variability in patient factors such as lipoma type, patient age, and methods of (particularly urological) assessment. Currently, there is insufficient evidence base upon which to make clear recommendations for the management of children with LSL. There is an imperative for neurosurgeons, neuroradiologists, and urologists to collaborate to better standardise the terminology, assessment tools, and surgical interventions for this challenging group of conditions.
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Affiliation(s)
- Duranka Perera
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | - Claudia L Craven
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK
| | - Dominic Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, UK.
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Morota N, Sakamoto H. Surgery for spina bifida occulta: spinal lipoma and tethered spinal cord. Childs Nerv Syst 2023; 39:2847-2864. [PMID: 37421423 DOI: 10.1007/s00381-023-06024-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023]
Abstract
The technical evolution of the surgery for spina bifida occulta (SBO) over the course of a half-century was reviewed with special foci placed on the spinal lipoma and tethered spinal cord. Looking back through history, SBO had been included in spina bifida (SB). Since the first surgery for spinal lipoma in the mid-nineteenth century, SBO has come to be recognized as an independent pathology in the early twentieth century. A half-century ago, the only option available for SB diagnosis was the plain X-ray, and pioneers of the time persevered in the field of surgery. The classification of spinal lipoma was first described in the early 1970s, and the concept of tethered spinal cord (TSC) was proposed in 1976. Surgical management of spinal lipoma with partial resection was the most widely practiced approach and was indicated only for symptomatic patients. After understanding TSC and tethered cord syndrome (TCS), more aggressive approaches became preferred. A PubMed search suggested that there was a dramatic increase of publications on the topic beginning around 1980. There have been immense academic achievements and technical evolutions since then. From the authors' viewpoint, landmark achievements in this field are listed as follows: (1) establishment of the concept of TSC and the understanding of TCS; (2) unraveling the process of secondary and junctional neurulation; (3) introduction of modern intraoperative neurophysiological mapping and monitoring (IONM) for surgery of spinal lipomas, especially the introduction of bulbocavernosus reflex (BCR) monitoring; (4) introduction of radical resection as a surgical technique; and (5) proposal of a new classification system of spinal lipomas based on embryonic stage. Understanding the embryonic background seems critical because different embryonic stages bring different clinical features and of course different spinal lipomas. Surgical indications and selection of surgical technique should be judged based on the background embryonic stage of the spinal lipoma. As time flows forward, technology continues to advance. Further accumulation of clinical experience and research will open the new horizon in the management of spinal lipomas and other SBO in the next half-century.
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Affiliation(s)
- Nobuhito Morota
- Department of Neurosurgery, Kitasato Universicy Hospital, 1-15-1 Kitasato, Minami-Ku, Sagamihara, 252-0375, Japan.
| | - Hiroaki Sakamoto
- Department of Pediatric Neurosurgery, Osaka City General Hospital, 2-13-22 Miyakojima-Hondori, Miyakojima-Ku, Osaka, 534-0021, Japan
- Department of Neurosurgery, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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Foo YW, Lim JX, Primalani NK, Ng LP, Seow WT, Low DCY, Low SYY. Tethered cord secondary to focal nondisjunction of the primary neural tube: experience from a Singapore children's hospital. Br J Neurosurg 2022:1-7. [PMID: 36564943 DOI: 10.1080/02688697.2022.2159931] [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: 09/08/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE Tethered cord due to focal nondisjunction of primary neuralisation (FNPN) is a rare form of spinal dysraphism. We present our institutional experience in managing children diagnosed with FNPN. MATERIALS AND METHODS This is a single institution, retrospective study approved by the hospital ethics board. Patients below 18 years of age diagnosed with CDS, LDM or their mixed lesions, and subsequently underwent intervention by the Neurosurgical Service, KK Women's and Children's Hospital, are included. RESULTS From 2001 to 2021, 16 FNPN patients (50% males) were recruited. Eight of them had CDS (50.0%), seven had LDM (43.8%), and one patient had a mixed CDS and LDM lesion (6.2%). The average duration of follow up was 5.7 years and the mean age of surgery was 6 months old. Thirteen patients underwent prophylactic intent surgery (81.2%) and three had therapeutic intent surgery (18.8%). All patients did not have new neurological deficit or required repeat surgery for cord retethering. We observed that detethering surgery performed at or less than three months old was associated with having a wound infection (p = .022). CONCLUSIONS Our study reports that early recognition and timely intervention are mainstays of management for FNPN. We advocate a multi-disciplinary approach for good outcomes.
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Affiliation(s)
- Yi Wen Foo
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | | | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
- Department of Neurosurgery, National Neuroscience Institute, Singapore
- Neuroscience Academic Clinical Program, SingHealth Duke-NUS, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
- Department of Neurosurgery, National Neuroscience Institute, Singapore
- Neuroscience Academic Clinical Program, SingHealth Duke-NUS, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore
- Department of Neurosurgery, National Neuroscience Institute, Singapore
- Neuroscience Academic Clinical Program, SingHealth Duke-NUS, Singapore
- Paediatrics Academic Clinical Program, SingHealth Duke-NUS, Singapore
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Vetrano IG, Barbotti A, Erbetta A, Mariani S, Bova SM, Colombo L, Caretti V, Marinoni F, Vestri E, Selvaggio GGO, Valentini LG. Multidisciplinary Management of Children with Occult Spinal Dysraphism: A Comprehensive Journey from Birth to Adulthood. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101546. [PMID: 36291482 PMCID: PMC9601159 DOI: 10.3390/children9101546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
Occult spinal dysraphism (OSD) comprises different forms of failure in embryogenic development that can lead to genitourinary, spinal, or lower limb alterations, thus determining progressive neurological deterioration. The correct management of children harboring OSD represents a significant issue during their life up to adulthood. However, patients often have to entertain individual consultations with each specialist. We settled on a multidisciplinary team comprising pediatric neurosurgeons, urologists, neurologists, orthopedists, and other supporting physicians. We present the results of such actions by analyzing a series of 141 children with OSD subjected to neurosurgical procedures, evaluating the impact of multidisciplinary management on outcomes. We also evaluated the specific actions according to the different ages of OSD patients from birth to adulthood to provide a schematic plan that could represent a basis for establishing and disseminating the need for a multidisciplinary approach in OSD management. The multidisciplinary team allows all consultants to see the patient together, covering specific aspects of history and examination pertinent to their management. Offering a one-stop service prevents coordination issues between the different medical teams, avoids delays or cancellations of the various appointments, optimizes cost-effectiveness, and improves efficiency and parents’ satisfaction.
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Affiliation(s)
- Ignazio G. Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20133 Milan, Italy
- Correspondence:
| | - Arianna Barbotti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Alessandra Erbetta
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Sabrina Mariani
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Stefania M. Bova
- Pediatric Neurology Unit, Vittore Buzzi Children’s Hospital, 20154 Milan, Italy
| | - Luca Colombo
- Pediatric Orthopedics and Traumatology Unit, Vittore Buzzi Children’s Hospital, 20154 Milan, Italy
| | - Valentina Caretti
- Pediatric Orthopedics and Traumatology Unit, Vittore Buzzi Children’s Hospital, 20154 Milan, Italy
| | - Federica Marinoni
- Pediatric Surgery Unit, Vittore Buzzi Children’s Hospital, 20154 Milan, Italy
| | - Elettra Vestri
- Pediatric Surgery Unit, Vittore Buzzi Children’s Hospital, 20154 Milan, Italy
| | | | - Laura G. Valentini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
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Valentini LG, Vetrano IG. Letter to the Editor. Spinal column shortening for secondary TCS. J Neurosurg Pediatr 2021; 29:124-125. [PMID: 34598143 DOI: 10.3171/2021.6.peds21328] [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: 11/06/2022]
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Vetrano IG, Valentini LG. Letter: Posterior Vertebral Column Subtraction Osteotomy for Recurrent Tethered Cord Syndrome: A Multicenter, Retrospective Analysis. Neurosurgery 2021; 89:E135-E136. [PMID: 33890110 DOI: 10.1093/neuros/nyab150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/06/2021] [Indexed: 11/13/2022] Open
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Lee SH, Shin HI, Nam TK, Park YS, Kim DK, Kwon JT. Growth profile assessment of young adults with tethered cord syndrome: a retrospective cohort analysis of Korean conscription data. Childs Nerv Syst 2021; 37:1973-1981. [PMID: 33392650 DOI: 10.1007/s00381-020-05026-2] [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: 07/31/2020] [Accepted: 12/20/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Tethered cord syndrome (TCS) is characterized by progressive spinal cord degeneration secondary to congenital spinal dysraphism. The associated accompanying physical inactivity and musculoskeletal deformities have raised interest in the growth profile of adult TCS patients. However, few previous studies have investigated the growth profile of adult TCS patients. METHODS We retrospectively reviewed the demographic data and medical records of 20-year-old Korean conscription examinees who were registered between April 2004 and September 2019. In total, 151 examinees with a diagnosis of TCS were enrolled. The height, weight, and body mass index (BMI) of 300 randomly selected examinees were compared to the TCS group. Obesity was defined by the World Health Organization and Asian-Pacific criteria for BMI and compared between the groups. Growth profile differences according to tethering location and musculoskeletal deformities were analyzed in both groups. RESULTS The mean height, weight, and BMI values of the TCS group were lower than those of the control group. The TCS group had a lower proportion of obese and overweight individuals, and a higher proportion of underweight individuals, according to both BMI criteria. The tethering level was not associated with the degree of obesity in the tethered group. The mean height, weight, and BMI were lower in the tethered group regardless of the existence of musculoskeletal deformity. CONCLUSION Enrollees with a history of TCS were smaller than controls of the same age. Monitoring of health behaviors, including nutrition, diet, and exercise, is warranted for TCS patients.
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Affiliation(s)
- Shin Heon Lee
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, 06973, South Korea
| | - Hyun Iee Shin
- Department of Rehabilitation Medicine, College of Medicine, Chung-Ang University, Seoul, 06973, South Korea.
| | - Taek-Kyun Nam
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, 06973, South Korea
| | - Yong-Sook Park
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, 06973, South Korea
| | - Don-Kyu Kim
- Department of Rehabilitation Medicine, College of Medicine, Chung-Ang University, Seoul, 06973, South Korea
| | - Jeong-Taik Kwon
- Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, 06973, South Korea
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