Clinical observations on the release of tethered spinal cord in children with intra-operative neurophysiological monitoring: A retrospective study

Diagnosis and Treatment of Tethered Spinal Cord: A Systematic Review

CONTEXT

Tethered cord syndrome is associated with motor and sensory deficits.

OBJECTIVE

Our objective was to summarize evidence regarding the diagnosis, prophylactic surgery, symptomatic treatment, and repeat surgery of tethered spinal cord in a systematic review (CRD42023461296).

DATA SOURCES AND STUDY SELECTION

We searched 13 databases, reference-mined reviews, and contacted authors to identify diagnostic accuracy studies and treatment studies published until March 2024.

DATA EXTRACTION

One reviewer abstracted data, and a content expert checked the data for accuracy. We assessed the risk of bias, strength of evidence (SoE), and applicability.

RESULTS

The evidence base includes 103 controlled studies, many with risk of bias and applicability concerns, and 355 case series providing additional clinical information. We found moderate SoE for MRI diagnosing tethered spinal cord, with medium to high diagnostic sensitivity and specificity. A small number of prophylactic surgery studies suggested motor function benefits and stability of neurologic status over time, but also complications such as surgical site infection (low SoE). A larger body of evidence documents treatments for symptomatic patients; studies revealed improvement in neurologic status after surgical detethering (low SoE), but also postoperative complications such as cerebrospinal fluid leakage (moderate SoE). A small body of evidence exists for retethering treatment (low or insufficient SoE for all outcomes).

LIMITATIONS

There was insufficient evidence for key outcomes (eg, over- or undertreatment, clinical impact of diagnostic modalities, ambulation, quality of life).

CONCLUSIONS

This comprehensive overview informs difficult clinical decisions that parents and their children with tethered spinal cords, as well as their health care providers, face.

Application of neurophysiological monitoring during tethered cord release in children

OBJECTIVE

The objective of this study was to explore the effect of intraoperative neurophysiological monitoring (IONM) on tethered spinal cord release in children.

METHODS

The clinical data of 454 children with tethered cord syndrome who underwent surgery for tethered cord release were retrospectively analyzed. The children were divided into two groups: the non-IONM group and the IONM group. SPSS 26.0 software was used for statistical analysis. The evaluation indices included the effective rate and incidence of new neurological dysfunction.

RESULTS

The short-term results showed that the effective rate of the non-IONM group was 14.8%, while that of the IONM group was 15.2%. Additionally, the incidence of new neurological dysfunction was 7.8% in the non-IONM group and 5.6% in the IONM group. However, there was no significant difference between the two groups (P > 0.05). The medium- to long-term follow-up had significant difference (P < 0.05), the response rate was 32.1% in the IONM group and 23.7% in the non-IONM group, and deterioration rates regarding neurological dysfunction were 3.3% in the IONM group and 8.5% in the non-IONM group.

CONCLUSION

This study revealed that the use of IONM does not significantly improve the short-term treatment effect of patients undergoing surgery for tethered cord release or reduce the short-term incidence of postoperative new neurological dysfunction. However, the medium- to long-term prognoses of patients in the IONM group were better than those of patients in the non-IONM group.

Intraoperative neurophysiological monitoring in paediatric neurosurgery

Intraoperative neurophysiological monitoring (IONM) is commonly used in various surgical procedures in adults, but with technological and anaesthetic advancements, its use has extended to the paediatric population. The use of IONM in children poses a unique set of challenges considering the anatomical and physiological differences in this group of patients. The use of IONM aids in the localization of neural structures and enables surgeons to preserve the functional neural structures leading to decreased incidence of postoperative neurological deficits and better patient outcomes. In this article, we review the use of IONM in paediatric patients undergoing various spinal and cranial neurosurgical procedures. We discuss the patient characteristics, type of surgeries, and technical and anaesthetic considerations about IONM in this population.

Anesthesia for Innovative Pediatric Surgical Procedures

Over the past few decades, there have been many advances in pediatric surgery, some using new devices (eg, VEPTR, MAGEC rods) and others using less invasive approaches (eg, Nuss procedure, endoscopic cranial suture release, minimally invasive tethered cord release). Although many of these procedures were initially met with caution or skepticism, continued experience over the past few decades has shown that these procedures are safe and effective. This article reviews the anesthetic considerations for these conditions and procedures.