Split cord malformation and tethered cord syndrome: case series with long-term follow-up and literature review

Quality of Life of Children Treated for Split Cord Malformation

OBJECTIVE

Split cord malformation (SCM), associated with neurologic deficits, necessitates surgical intervention for spinal cord detethering. Limited evidence exists regarding its impact on children's quality of life. Our study aims to evaluate the postoperative quality of life in children treated for SCM.

METHODS

This retrospective cohort study examined records of patients with SCM operated on between July 1, 2012, and July 31, 2022, at a single center. Data, including Health Utility Index-3 (HUI-3) scores provided by guardians, was collected to assess quality of life. Clinical and neurologic outcomes were also analyzed.

RESULTS

Twenty-five patients, predominantly female (68%), with a median age of 7 years, were included. Most presented with normal motor function (76%). The most common anatomic level of SCM was lumbar (12; 48%) followed by lumbosacral (5; 20%). A bony spur from the lamina was the most common cause of splitting the cord (64%). Over a median follow-up of 3.3 years, 64% of patients showed neurologic stability, 16% showed neurologic improvement, and 4% experienced deterioration. The mean HUI-3 score for 21 children was 0.93 ± 0.24.

CONCLUSIONS

Surgical management of SCM showed favorable neurologic outcomes and a positive long-term quality of life, as shown by HUI-3 scores. Our findings emphasize the efficacy of surgical intervention in improving the lives of children with this condition.

Preliminary Experience with 3-Dimensional-Exoscopic Untethering of a Type II Diastematomyelia: Technical Note and Review of the Literature

OBJECTIVE

To describe the use of a high-definition 3-dimensional (3D) exoscope (VITOM 3D exoscope; KARL STORZ GmbH) for the neurosurgical treatment of a rare pediatric disease, type II diastematomyelia with associated tethered cord.

METHODS

A 13-year-old girl who presented with diastematomyelia type II with a tethered cord was surgically treated with the aid of a high-definition 3D exoscope, with a third operator moving and pivoting its arm. Intraoperative monitoring and mapping were arranged. The surgery required a bilateral access to address both the split cord malformation and the tethering of the filum terminale. The filum terminale was identified and cut, and the connective fibrovascular tissue separating the 2 medullary halves was unraveled. These steps were performed with no changes of intraoperative monitoring. Pertinent literature was addressed carefully.

RESULTS

The surgery was successful, and the patient was discharged home on the eleventh postoperative day without any complications. The 3-month postoperative magnetic resonance imaging scan demonstrated regular surgical outcomes; no dynamic motor disturbances were reported. To our knowledge, this is the first spinal congenital malformation treated with the use of a 3D exoscope.

CONCLUSIONS

The use of 3D exoscope is advancing in spinal surgery, as it provides magnification, stereopsis, lighting, and definition comparable with the operating microscope; the addition of a third operator simplified the operations of moving around the arm, releasing these burdens for the surgeons. Our preliminary experience proved that the use of a 3D exoscope is feasible and safe for the surgical management of a type II diastematomyelia with tethered cord.

Current Global Research Trends of Tethered Cord Syndrome Surgery: A Scientometric and Visual Analysis

BACKGROUND

Since tethered cord syndrome (TCS) may lead to neurologic and motor dysfunction, surgeries often are applied to relieve the symptoms. The aim of the research was to explore the current global research trends of TCS surgery.

METHODS

In this article, articles on TCS surgery in the Web of Science Core Collection from 1980 to 2023 were searched. Research trends, countries, institutions, journals, authors, highly cited articles, and key words were analyzed using bibliometric methods. The literature co-citation network was mapped using VOSviewer, and research hotspots and trends were analyzed using CiteSpace.

RESULTS

A total of 432 publications were included. The number of publications and related research interest in the field of TCS surgery has increased globally year by year. The United States is the largest contributor (154 publications). The journal Childs Nervous System has the greatest number of publications (48 publications) and the most frequently cited journal is Neurosurgery (973 citations). In network visualization, the institution with the greatest contribution is University of California System (16 publications). Lee JY and Wang KC are the authors with the greatest number of publications (8 publications), and the most frequently cited author is Klekamp J (268 citations). Neurogenic bladder and spina bifida may be the next hot spot in this field.

CONCLUSIONS

This study will help researchers to identify the mainstream research directions and the latest hotspots in the field of TCS surgery and provide a reference for further research.

Dekyphosis operation combined with limited osteotomy to treat the symptomatic adult tethered cord syndrome with complicated malformations: A case report

RATIONALE

Tethered cord syndrome (TCS) represents a spectrum of neurological symptoms that are caused by constant or intermittent axial traction of the terminal cone of the spinal cord due to abnormal positioning. It is uncommon for abnormal structures of TCS to be accompanied by split cord malformation, thoracic spinal stenosis, and other spinal cord diseases.

PATIENT CONCERNS

A 45-year-old male patient visited our hospital due to severe lower back pain, extensive left lower limb muscle weakness, and intermittent claudication.

DIAGNOSES

TCS combined with stenosis of the thoracic canal, split cord malformation, and kyphosis deformity.

INTERVENTIONS

The patient underwent Dekyphosis operation combined with limited osteotomy symptoms.

OUTCOMES

The patient felt the right lower limb improved after surgery. At 4-month follow-up, a radiological examination showed adequate decompression of the spinal cord and a good internal fixation position. Overall, the patient's clinical symptoms significantly improved.

CONCLUSION

This is a rare case of TCS combined with thoracic disc herniation and bony mediastinum. A more conservative invasive surgical approach was elected and markedly improved the patient's symptoms. Additional clinical cases are needed to confirm the stability and feasibility of this surgical approach.

A Case of Neonate with Split Cord Malformation Presenting with Hypoplasia of the Left Lower Extremity

The frequency of split cord malformation (SCM) is approximately 1 in 5000 births; however, patients are rarely diagnosed with SCM in the neonatal period. Moreover, there have been no reports of SCM with hypoplasia of the lower extremities at birth. A 3-day-old girl was transferred to our hospital for a thorough examination of hypoplasia of the left lower extremity and lumbosacral abnormalities detected after birth. The spinal magnetic resonance imaging (MRI) revealed a split spinal cord in a single dural tube. Based on the MRI findings, the patient was diagnosed with SCM type II. Following discussions with the parents, pediatricians, neurosurgeons, psychologists, and social workers, we decided to perform untethering to prevent further neurological impairment after achieving a sufficient body weight. The patient was discharged on day 25 of life. Early diagnosis and intervention may improve the neurological prognosis in terms of motor function, bladder and bowel function, and superficial sensation; thus, clinicians should report infrequent findings that may lead to SCM diagnosis. SCM should be differentiated in patients with left-right differences in the appearance of the lower extremity, particularly in those with lumbosacral abnormalities.

Ischemic myelomalacia and closed spinal dysraphism in multiple finishing swine

Ischemic myelomalacia secondary to fibrocartilaginous emboli (FCE) is an idiopathic disease in humans and animals. On the other hand, congenital spinal cord malformations result from neural tube defects in fetal development (ie, spinal dysraphism), with structural anomalies referred to collectively as myelodysplasia. Spinal dysraphisms are frequently accompanied by skin and vertebral abnormalities because of the embryogenic relationship. In this observational case study, we report the pathologic findings of 13, 18- to 24-weeks-old pigs from a large conventional operation that presented with acute paraparesis. Ischemic myelomalacia secondary to FCE was observed in 5 of 13 examined pigs. Congenital spinal cord malformations located between the caudal thoracic and sacral spinal cord were identified in 7 pigs, with structural abnormalities that ranged from diplomyelia/split cord malformation to segmental spinal dysgenesis (myelodysplasia) to caudal agenesis. Concurrent myelomalacia and congenital spinal cord malformations in the same or different sites were noted in 2 pigs. No spinal lesion was observed in 3 pigs. Although gross vertebral abnormalities were not observed herein, intervertebral instability due to minor defects in the articular facets, as well as other unidentified factors, is suspected to contribute high incidence of FCE. It is likely that these congenital malformations were previously underdiagnosed or are possibly new conditions associated with continuous inbreeding and genetic improvement in the modern swine industry.

Gastrulation and Split Cord Malformation

Split cord malformation (SCM) is a rare form of closed spinal dysraphism, in which two hemi-cords are present, instead of a single spinal cord. SCM is categorised into type 1 and type 2. Type 1 SCM is defined by the presence of a bony or osseocartilaginous spur between the hemi-cords, whereas type 2 SCM has no bony spur, and the two hemi-cords are contained within a single dura. In this chapter, we present the putative mechanisms by which SCM arises, including gastrulation defects and Pang's unified theory. The typical and rare clinical presentations and variations are described. Finally, we outline the step-by-step surgical approach to both SCM 1 and 2 and the overall prognosis of both conditions.

Thoracolumbar surgery for degenerative spine diseases complicated with tethered cord syndrome: A case report

BACKGROUND

Tethered cord syndrome (TCS) secondary to split cord malformation (SCM) is rare in adulthood. There is as yet no consensus about the optimal treatment method for adult patients with SCMs and degenerative spine diseases such as lumbar stenosis, spondylolisthesis and ossification of the ligamentum flavum (OLF). The tethered cord poses a great challenge to the decompression and fusion procedures for the intraoperative stretching of the spinal cord, which might lead to deteriorated neural deficits. Here, we report on a case to add our treatment experience to the medical literature.

CASE SUMMARY

We treated a 67-year-old female patient with type II SCM suffering from lumbar disc herniation, degenerative lumbar spondylolisthesis and thoracic OLF. The patient underwent thoracolumbar spinal fusion and decompression surgery for severe lower back pain, extensive left lower limb muscle weakness and intermittent claudication. After the thoracolumbar surgery, without stretching the tethered cord, the patient achieved complete relief of pain and lower extremity weakness at final follow-up.

CONCLUSION

For adult patients with underlying TCS secondary to SCM coupled with thoracic OLF and lumbar spondylolisthesis, a thoracolumbar fusion surgery could be safe and effective with the tethered cord untreated. It is critical to design individualized surgical protocols to reduce the stretch of the low-lying spinal cord.

A systematic review and meta-analysis of minimally invasive surgery in children with occult tethered cord syndrome

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.

Treatment of spinal deformity with diastematomyelia type I: one-stage, two-stage surgery and new technique (vertebral column resection through wide bony septum)

STUDY DESIGN

Case series, literature review, and technical note.

OBJECTIVES

To compare two different approaches to treat the spinal deformity with split cord malformation type I (SCM I). To present a new method of one-stage surgical treatment of congenital spinal deformity with wide bony septum (SCM I).

METHODS

Analysis of the literature on the different types of combined surgical treatment of spinal deformities with SCM I was performed. We have provided our own data on 27 patients treated for congenital spinal deformity and SCM I, one of which underwent Schwab IV type osteotomy at the apex of the deformity through the bony septum and pedicles. Inclusion criteria were presence of spinal deformity in combination with SCM 1, performed surgery to correct spinal deformity, and follow-up period of at least 2 years.

RESULTS

The result of the literature review was controversial and requires additional research. The average age of patients was 8.8 ± 6.6 years old. One-stage treatment of SCM I and spinal deformity was performed in 10 patients (group I) and two-stage in 14 patients (group II). Three patients with severe myelodysplasia, SCM I, and congenital kyphoscoliosis underwent correction of spinal deformity without SCM I removing (group III). The group I had the longest surgery duration (mean 289 ± 75 min) and largest blood loss (mean 560 ± 386 ml), a high percentage of deformity correction (mean 69.6%), and the highest rate of complications (60%). The most optimal was the two-stage treatment with the mean surgery duration 191 ± 137 min, mean blood loss 339 ± 436 ml, mean correction rate 63%, and frequency of complications 21%. The average follow-up time was 6.0 ± 2.6 years.

CONCLUSIONS

One stage surgery associated with a large surgical invasion and a large number of complications. It can be used in some cases, for example when the wide bony septum (SCM I) is localized at the apex of the congenital scoliosis or kyphosis. In all other cases, it is worth adhering to a two-stage treatment. Many new works demonstrate the relative safety and effectiveness of deformity correction without removing the SCM. In our opinion, indications for treatment of spinal deformity without SCM I removing can be the need to perform a shortening ostetomy outside the SCM zone. The remaining cases require a thorough assessment and a balanced decision.