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Casado-Ruiz J, Ros B, Iglesias S, Ros A, Arráez MA. Spinal cord lipomas: lessons learned in the era of total resection. Childs Nerv Syst 2024; 40:1121-1128. [PMID: 38103091 DOI: 10.1007/s00381-023-06251-1] [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: 09/06/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Recent years have seen a paradigm shift towards total/near-total resection in spinal cord lipoma surgery. As this procedure is technically challenging, surgical candidates need to be selected appropriately through accurate image assessment and classification. The purpose of this paper is to describe a surgical series of paediatric spinal cord lipomas, their diagnosis, results and complications. METHODS We undertook a retrospective review of paediatric patients with spinal cord lipomas who underwent surgery between 2008 and 2022. The variables studied were age, gender, preoperative symptoms according to the Necker Functional Score (NFS), type of lipoma according to Morota's classification, functional and radiological surgical outcomes using the cord-sac ratio (CSR), need for re-operation, complications and follow-up. RESULTS A total of 25 patients (average age 36 months) underwent surgery. According to Morota's classification, MRI showed 13 type 1 lipomas, two type 2, two type 3 and eight type 4. The preoperative NFS was 16.06, with urological abnormalities being the most frequent manifestation. Total/near-total resection was attempted since 2015. Five patients with type 1 lipoma required re-operation due to clinical deterioration with suspected retethering, all of them with a CSR > 0.3. The series average CSR was 0.417. CONCLUSIONS This paper highlights the importance of proper classification for a correct surgical approach to obtain favourable results and minimise possible complications. Based on our experience, given our results regarding the percentage of fistulae and retethering rates, we limited radical resection to symptomatic type 1 lipomas. Our future aim is to obtain better CSR rates and to decrease the retethering percentage.
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Affiliation(s)
- Julia Casado-Ruiz
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain.
| | - Bienvenido Ros
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
| | - Sara Iglesias
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
| | - Angela Ros
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
| | - M A Arráez
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Málaga, Spain
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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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Lim JX, Fong E, Goh C, Ng LP, Low DCY, Seow WT, Low SYY. Complex lumbosacral spinal cord lipomas: A longitudinal study on outcomes from a Singapore children's hospital. J Clin Neurosci 2024; 121:119-128. [PMID: 38394955 DOI: 10.1016/j.jocn.2024.02.017] [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: 09/22/2023] [Revised: 01/28/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Total/near-total resection (TR/NTR) of complex lumbosacral lipomas (CSL) is reported to be associated with better long-term functional outcomes and lower symptomatic re-tethering rates. We report our institutional experience for CSL resection in affected children. METHODS This is a single-institution, retrospective study. Inclusion criteria consist of patients with CSL with dorsal, transitional and chaotic lipomas based on Pang et al's classification. The study population is divided into 2 groups: asymptomatic patients with a normal preoperative workup referred to as 'prophylactic intent' and 'therapeutic intent' for those with pre-existing neuro-urological symptoms. Primary aims are to review factors that affect post-operative clean intermittent catheterization (CIC), functional outcomes based on Necker functional score (NFS), and re-tethering rates. RESULTS 122 patients were included from 2000 to 2021. There were 32 dorsal lipomas (26.2 %), 74 transitional lipomas (60.7 %), and 16 chaotic lipomas (13.1 %). 82 % patients achieved TR/NTR. Favourable NFS at 1-year was 48.2 %. The re-tethering rate was 6.6 %. After multivariable analysis, post-operative CIC was associated with median age at surgery (p = 0.026), lipoma type (p = 0.029), conus height (p = 0.048) and prophylactic intent (p < 0.001). Next, extent of lipoma resection (p = 0.012) and the post-operative CSF leak (p = 0.004) were associated with re-tethering. Favourable NFS was associated with lipoma type (p = 0.047) and prophylactic intent surgery (p < 0.001). CONCLUSIONS Our experience shows that TR/NTR for CSL is a feasible option to prevent functional deterioration and re-tethering. Efforts are needed to work on factors associated with post-operative CIC.
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Affiliation(s)
- Jia Xu Lim
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - Elizabeth Fong
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - Cheryl Goh
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, ,00 Bukit Timah Road, Singapore 229899, Singapore; Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; SingHealth Duke-NUS Paediatrics Academic Clinical Program, 100 Bukit Timah Road, Singapore 229899, Singapore.
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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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Idriceanu T, Beuriat PA, Di Rocco F, Szathmari A, Mottolese C. Recurrent tethering in conus lipomas: a late complication not to be ignored. World Neurosurg 2022; 168:e12-e18. [PMID: 35863646 DOI: 10.1016/j.wneu.2022.07.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUNDS Recurrent symptomatic tethered cord (RTC) is a long-term complication of spinal cord lipomas, responsible for progressive motor deficits, urologic dysfunction and aggravation of spinal deformities.We retrospectively analysed all cases of recurrent tethering after spinal cord lipoma surgery, the clinical and radiological features that led to the diagnosis, the surgical management and the neuro-orthopedic outcome at the last follow-up. METHODS The study was carried out over a period of 20 years on a total of 209 pediatric patients from a single institution, initially treated for a conus lipoma. RESULTS 9 patients (4,8 %) were surgically treated for a RTC. The age at retethering ranged from 2 to 12 years -median of 7, 4 years. The time before the first and the second surgical procedure, ranged from 19 to 140 months - median of 7 years and a half. The follow-up period after the second surgery ranged from 3 months to 13 years with a median of 50 months. Among symptoms, pain responded very well to surgery. Gait disturbances improved in 50 % after the surgery. One patient with bladder dysfunctions also improved. The rest of the patients maintained the pre-surgical status. CONCLUSIONS When RTC is confirmed, child should be referred to surgery as soon as possible, as we showed that the post- operative clinical outcome improved and surgery did not worsen patients. We stressed the fact that the follow-up should be as long as possible for these patients.
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Affiliation(s)
- T Idriceanu
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677 Lyon Cedex, France
| | - P A Beuriat
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677 Lyon Cedex, France
| | - F Di Rocco
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677 Lyon Cedex, France
| | - A Szathmari
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677 Lyon Cedex, France
| | - C Mottolese
- Department of Pediatric Neurosurgery, Hôpital Femme Mère Enfant, 32 Avenue du Doyen Jean Lépine, 69677 Lyon Cedex, France.
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