Prevalence of spina bifida occulta in patients with functional disorders of the lower urinary tract and its relation to urodynamic and neurophysiological measurements

Complete dorsal wall agenesis of the sacral canal in a Greek population: an osteological study

INTRODUCTION

The failure of closure of the dorsal wall of the sacral canal (SC) has been known since the eve of modern osteology, appearing in prehistoric times. Variants include partial or complete absence of the dorsal wall of the SC. SC presents a pathway for minimally invasive therapeutic and diagnostic procedures for spinal diseases and for ensuring analgesia and anesthesia in operations, including labor and genitourinary surgery.

Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change

Substantial relaxation of natural selection beginning around 1900 changed the mutation/selec­tion balance of modern genetic material, producing an increase in variable anatomical structures. While multiple structures have been affected, the temporal increase in variations of the sacrum, specifically, ‘Sa­cral Spina Bifida Occulta,’ have been reliably demonstrated on a localised scale. Calculation of largescale frequency has been hindered by the localised nature of these publications, the morphological variability of this variation, and potential pathological associations, which have produced divergent classifications, and conflicting reported rates of occurrence. A systematic review of the reported literature was conducted to provide an objective analysis of Sacral Spina Bifida Occulta frequency from 2500 BCE to the present. This review was designed to compensate for observed inconsistencies in reporting and to ascertain, for the first time, the temporal trajectory of this secular trend. A systematic review of Sacral Spina Bifida Occulta lit­erature was conducted through the strict use of clinical meta-analysis criteria. Publications were retrieved from four databases: PubMed, Embase, the Adelaide University Library database, and Google Scholar. Data were separated into three historical groups, (1 = <1900, 2 = 1900 to 1980 and 3 = >1980), and frequency outcomes compared, to determine temporal rates of occurrence. A total of 39/409 publications were included in the final analysis, representing data for 16,167 sacra, spanning a period of 4,500 years. Statistically significant results were obtained, with total open S1 frequen­cy increasing from 2.34%, (79 to 1900CE), to 4.80%, (1900 to 1980CE) and to 5.43% (>1980CE). These increases were significant at p<0.0001, with Chi-squared analysis. A clear secular increase in the global frequency of Sacral Spina Bifida Occulta has been demonstrated from 1900 to the present. This research provides a novel and adaptable framework for the future assessment of variation distribution, with impor­tant implications for the fields of biological anthropology and bioarchaeology.

Spina Bifida Occulta Is a Risk Factor for Spinal Cord Injury Without Fracture or Dislocation for Children Performing a Backbend During Dance

OBJECTIVE

This study aimed to explore the clinical features and outcomes of children with spinal cord injury (SCI) without fracture or dislocation.

METHODS

The clinical data of children with SCI without fracture or dislocation in this retrospective study were collected in Chongqing, China (January 2010 to December 2021). We collected patient demographics at admission including age, gender, cause, level, and severity of the injury in admission and complications. Reports from radiologic imaging were reviewed to identify spina bifida occulta (SBO). Neurological function was evaluated using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) for an SCI.

RESULTS

A total of 74 children with SCI (male, 27%; female, 73%; male-to-female ratio, 1:2.7; average age, 5.7 years) were included. The main cause of injury was backbend during the dance (34 patients, 45.9%, including 2 patients who hugged back falling backward), followed by traffic accidents (17 patients, 23%). Children with backbend-related SCI were older than other children (6.9 vs. 4.9 years old, P < 0.001). When reviewing all radiological images, it was found that 20 (27%) patients with SCI had SBO. The proportion of SCI with SBO caused by backbend was considerably higher than those caused by non-backbend (41.2 vs. 15%, P = 0.012). The AIS were 22 (29.7%), 4 (5.4%), 8 (10.8%), 31 (41.9%), and 9 (12.2%) in A, B, C, D, and E, respectively. The prognosis was poorer in the backbend during dancing than other causes of injury (p = 0.003).

CONCLUSION

This study showed that backbend during the dance was the main cause of children's SCI without fracture or dislocation in Chongqing, China. The prognosis was poorer in those children than in other causes of injury. Meanwhile, we have established an association between SBO and SCI for children performing a backbend during the dance.

The paleoepidemiology of Sacral Spina Bifida Occulta in population samples from the Dakhleh Oasis, Egypt

OBJECTIVE

To document sacral spina bifida occulta (SSB0) prevalence in a population sample from the Dakhleh Oasis, Egypt, and address methodological issues in recording and quantifying SSBO variations.

MATERIALS

442 adult sacra from two temporally disjunct samples from the same deme traversing the 3rd intermediate (TIP) and the Roman Periods.

METHODS

Sacra were scored for SSBO, excluding the sacral hiatus. Risk of SSBO was calculated with the common odds ratio and statistical significance by X². Data were compared to other archaeological SSBO data.

RESULTS

SSBO was present in 15.6% of the sample with a slight, but not significant, temporal increase (TIP to Roman Period) in males, and a significant age-correlated increase in both sexes. Most open sacra occurred in young adults.

CONCLUSIONS

Data support that SSBO can be considered as a morphogenetic variant. Dakhleh data fall within the prevalence range for most populations, however inter-population comparisons are complicated by methodological inconsistencies.

SIGNIFICANCE

SSBO can be used in paleogenetic research.

LIMITATIONS

Methodological differences in scoring SSBO prevent effective comparative study.

SUGGESTED FUTURE RESEARCH

Future studies require more rigorous and standardized scoring methods. aDNA may be used to corroborate the morphogenetic value of SSBO and determine its clinical significance.

Prevalence of Spina Bifida Occulta and Its Relationship With Overactive Bladder in Middle-Aged and Elderly Chinese People

PURPOSE

To investigate the prevalence of spina bifida occulta (SBO) and its relationship with the presence of overactive bladder (OAB) in middle-aged and elderly people in China.

METHODS

A cross-sectional community-based survey was carried out at 7 communities in Zhengzhou City, China from December 15, 2013 to June 10, 2014, where residents aged over 40 years were randomly selected to participate. All of the participants underwent lumbosacral radiographic analysis and relevant laboratory tests. A questionnaire including basic information, past medical history and present illness, and the OAB symptom score was filled out by all participants. Chi-square tests and logistic regression were used for data analysis with a P-value of <0.05 denoting statistical significance.

RESULTS

A total of 1,061 subjects were qualified for the final statistical analysis (58.8±11.7 years; male, 471 [44.4%]; female, 590 [55.6%]). The overall prevalence of SBO was 15.1% (160 of 1,061): 18.3% (86 of 471) in men and 12.5% (74 of 590) in women. Among these subjects, 13.7% (145 of 1,061) had OAB: 13.2% (62 of 471) in men and 14.1% (83 of 590) in women. The results of logistic regression showed that age, SBO, history of cerebral infarction (HCI), and constipation were risk factors for OAB (P<0.05), while sex, history of childhood enuresis (HCE), body mass index (BMI), and diabetes mellitus (DM) were not (P>0.05). In men, age, SBO, and constipation were risk factors for OAB (P<0.05), while HCE, BMI, DM, HCI, and benign prostate hyperplasia were not (P>0.05). In women, age, SBO, and HCI were risk factors for OAB (P<0.05), while HCE, BMI, DM, vaginal delivery, and constipation were not (P>0.05).

CONCLUSIONS

The prevalence of SBO is high and it is related to OAB in middle-aged and elderly people in China.

Spina bifida occulta: not to be overlooked in children with nocturnal enuresis

OBJECTIVE

Previous reports have suggested that the incidence of spina bifida occulta in patients with nocturnal enuresis is higher than in the general population. However, the effect of spina bifida occulta on the response to nocturnal enuresis treatment is controversial. The purpose of this study was to investigate the relationship between spina bifida occulta and response to treatment of nocturnal enuresis.

METHODS

Between 2006 and 2009, the records of 160 children with nocturnal enuresis were reviewed. Children with other organic urological disease or symptoms suggestive of spinal dysraphism were excluded. Plain radiography for the kidney-ureter-bladder was carried out before the start of the nocturnal enuresis treatment. Response to treatment of children with and without spina bifida occulta was compared.

RESULTS

Of 160 children, 53 were girls; the mean age was 7.8 ± 2.06 years. The mean duration of treatment was 8.7 ± 9.29 months. Spina bifida occulta was detected in 43 children (26.9%). Spina bifida occulta affected L4 in four children, L5 in 12 children, S1 in 26 children and S2 in one child. There was a significant difference between the spina bifida occulta and non-spina bifida occulta groups in terms of outcome (P=0.002), with a complete response more likely in children without spina bifida occulta (P=0.005). None of the children with primary non-mono symptomatic nocturnal enuresis and spina bifida occulta showed a complete response.

CONCLUSIONS

The presence of spina bifida occulta significantly affects the response to treatment in patients with nocturnal enuresis. Thus, verifying spina bifida occulta in this patient population can facilitate the prediction of the response to nocturnal enuresis treatment.

Confirmation of microevolutionary increase in spina bifida occulta among Swiss birth cohorts

Previous studies on the prevalence of spina bifida occulta have indicated a microevolutionary increase in its frequency and possible population differences in the prevalence of the condition. We studied the frequencies of closed and open sacral canals at each sacral level among two birth cohorts in Switzerland. Transverse CT scans and multiplanar reconstruction images of sacra of 95 males and 96 females born in 1940-1950 and 99 males and 94 females born in 1970-1980 in Switzerland were reviewed. We found that individuals born later have significantly more open sacral arches at all sacral levels compared to those born 30-40 years earlier. When results were related to previously published data on Australian cohorts, the trend was the same, but Swiss in both cohorts were less likely to have an open section than Australians at all locations apart from S2. This study confirmed a microevolutionary trend in the opening of sacral canal among two different generations in Switzerland and demonstrated a population difference in the prevalence of spina bifida occulta.

Secular trend in the opening of the sacral canal: an Australian study

STUDY DESIGN

Computer tomography scans were used to asses the opening of the sacral canal.

OBJECTIVE

We investigated the prevalence of sacral spina bifida occulta in 2 population groups: born 1940 to 1950 and 1980 to 1990.

SUMMARY OF BACKGROUND DATA

Comparison of the prevalence of spina bifida occulta in the first-century Pompeii with that in 20th century European and Mediterranean populations indicates that the degree of the closure of vertebral arches in the sacrum has undergone changes and the prevalence of spina bifida occulta is increasing.

METHODS

Transverse computer tomograph scans and multiplanar reconstruction images of sacra of 100 males and 100 females born 1940 to 1950 and 100 males and 100 females born 1980 to 1990 were used after ethics committee approval.

RESULTS

The individuals born later have significantly more open sacral arches when compared with those born 40 years earlier, especially in the midsacral region. Also, males have open sacral arches in the rostral segments of the sacrum more than females.

CONCLUSION

This study demonstrates a secular trend in the opening of the sacral canal in both sexes that occurred within 2 generations. Also, the increased prevalence of open sacral canal in males suggests a different response between sexes to the forces of evolution.

Constipation is associated with spina bifida occulta in children

BACKGROUND & AIMS

Spina bifida occulta (SBO) is a common developmental variant. The aim of this study was to re-examine the possible association between SBO and constipation in children.

METHODS

A total of 113 children with constipation underwent plain abdominal radiography, anorectal manometry, neurophysiologic study, electromyography testing, and colonic transit study. Eighty-six were diagnosed with functional constipation (FC) and 27 were diagnosed with nonretentive fecal incontinence (NRFI). The incidence of SBO in these children was compared with 226 sex- and age-matched controls. Twenty-four SBO children with either FC or NRFI also underwent individualized biofeedback training and electric stimulation therapy based on the investigation results.

RESULTS

The incidence of SBO in the FC and NRFI groups was 47.7% and 77.8%, respectively. Statistically, this is significantly higher than that of the control group (chi-square, 23.9%; P < .05). Compared with the FC or NRFI children without SBO, the FC and NRFI children with SBO had decreased vector volumes and electromyography amplitudes, increased rectal sensory thresholds, and prolonged latency of pudendo-anal reflex. All 24 children who underwent individualized biofeedback training and electrical stimulation treatment had sustained symptomatic improvement with less straining, fewer incomplete bowel movements, and less abdominal pain. The recovery rate was 79.2% (19 of 24).

CONCLUSIONS

Constipation in children is associated with increased incidence of SBO. Individualized biofeedback combined with electrical stimulation improves both the symptoms and the objective anorectal function measurements.

Spina bifida occulta: is it a predictor of underlying spinal cord abnormality in patients with lower urinary tract dysfunction?

OBJECT

The purpose of this study was to evaluate the importance of spina bifida occulta in radiographs of children with lower urinary tract or bowel dysfunction.

METHODS

The authors prospectively investigated the presence of spinal cord abnormalities in 176 patients with functional urinary and bowel problems: 88 children with radiographic evidence of spina bifida occulta (SBO) and 88 age-and sex-matched controls. Each group included 46 boys and 42 girls (age range 5-14 years). Nocturnal enuresis, isolated diurnal enuresis, enuresis during both day and night, urinary tract infection, urinary frequency, encopresis, intractable constipation, and vesicoureteral reflux were assessed in all patients. Magnetic resonance (MR) images were obtained in all patients and evaluated for spinal cord abnormalities. Sacral ratios (SRs) were calculated on the basis of plain radiographs.

RESULTS

There was no statistically significant difference between the 2 groups on any of the clinical measures. The most common sites of SBO on radiographs were the S-1 (47%) and L-5 and S-1 (25%). The mean SRs (+/-standard deviations) in the SBO and control groups, respectively, were 0.64+/-0.45 and 0.68+/-0.51 (no statistically significant difference). Sacral agenesis was found in 17 children (7 in the SBO group and 10 in the control group, p=0.44). Abnormal MR imaging findings were observed in 9 children (10.22%) in the SBO group and 3 (3.4%) in the control group. Abnormalities included tethered spinal cord in 5 children, syringomyelia in 4, and club-shaped conus in 2. No significant association was found between the presence of SBO and spinal cord abnormalities identified on MR images (p=0.13, paired t-test).

CONCLUSIONS

Among children with functional bowel and urinary problems, there was no statistically significant difference in the prevalence of abnormal spinal MR imaging findings in those with radiographic SBO and an age- and sex-matched control group. Spina bifida occulta was not shown to be a reliable indicator of spinal cord structural abnormalities. Its probable role as a finding associated with spinal cord dysfunction remains unclear.

[Vesicosphincteric and sexual disorders associated with spina bifida and myelomeningocele]

Neurogenic bladder secondary to spina bifida can have a very variable clinical presentation, but all forms share a common feature: a high risk of deterioration of the patient's quality of life and their life expectancy due to damage to the upper urinary tract. In this article, the authors present the epidemiological characteristics of this disease, its main clinical and urodynamic signs and discuss the prognosis of the disease, with particular emphasis on the value of close surveillance of these high-risk patients.

Minimal tethered cord syndrome: what's necessary to justify a new surgical indication?

✓Traditionally, surgical division of the terminal filum (filum terminale) has been reserved for patients with imaging-apparent spinal cord tethering. The occurrence of medically refractory voiding dysfunction of neurogenic origin, without magnetic resonance (MR) imaging documentation of abnormality in the spine, has been termed “minimal” tethered cord syndrome (TCS). The rationale for and utility of using surgical division of the terminal filum in the treatment of minimal TCS are unproven.

Six studies that involved surgical division of the terminal filum for minimal TCS were identified and reviewed. A seventh study conducted prior to the MR imaging era, in which authors used myelography, was also included. In addition, two investigations of the clinicopathological findings in such cases were analyzed. A tripartite criterion for justifying the introduction of a new surgical indication is proposed and analyzed in light of this evidence.

In children with minimal TCS there are definite pathological changes in the terminal filum that are not visible on routine spinal MR imaging. These changes suggest that the pathophysiology of minimal TCS, like TCS that is demonstrated on neuroimaging, may involve abnormal traction on the distal spinal cord. Additional data are needed regarding the sensitivity and specificity of various clinical studies intended to identify children with minimal TCS. All existing data supporting the efficacy of surgery for minimal TCS have been generated by Class III studies. Clinical equipoise exists for this surgical indication, and, therefore, a prospective randomized trial should be completed.

Radiographic method to assess the prevalence of sacral spina bifida occulta

Spina bifida occulta of the sacrum is the most common type of spinal deformity. Many authors have published data on the frequency of spina bifida occulta, with varying results. Some possible reasons for this variability could include the differing methods used to gather data and differing ways of classifying the condition. This study attempts to develop an X-ray method to study sacral spina bifida occulta in a standardized fashion, using an angulated antero-posterior technique. This technique is then used to estimate the frequency of sacral spina bifida occulta in an Australian sample. The sacra of 53 cadavers were X-rayed and the level of closure of the sacral spinal canal recorded. The X-ray technique was validated by open dissection of six of the cadavers studied and was shown to be accurate to half a sacral segment. No sacra with a completely open sacral canal were found, two sacra (4%) were open from S2 down to S5 and ten sacra (19%) were open from S3 down to S5. The most common condition (43%) recorded was where S4 and S5 only were open. Eighteen cadavers (34%) showed only S5 open, and interestingly, no sacra were recorded as having the dorsal sacral arch completely closed. A study of a larger sample will follow using the validated X-ray technique.

Occult tethered cord syndrome: the case for surgery

OBJECT

Controversy exists regarding proper indications for surgical lysis of the terminal filum in children with voiding dysfunction and tethered spinal cord. Recently, surgery has been offered to children who have a normally positioned conus medullaris and no terminal filum abnormality visible on 1.5-tesla magnetic resonance images (referred to as minimal or occult tethered cord syndrome [TCS]). The author evaluates existing clinical and scientific evidence relevant to this controversy.

METHODS

Five retrospective, observational, noncontrolled studies of surgical terminal filum lysis for occult TCS in children were identified. Two further studies in which the authors reported surgical results in children with a normal-level conus medullaris were also identified.

CONCLUSIONS

These studies document encouraging clinical outcomes following surgery. Clinicopathological evidence suggests that occult TCS may result from radiographically occult structural abnormalities of the terminal filum. Although a preponderance of Class III clinical evidence supports the use of surgical filum lysis to treat occult TCS, no Class I or II evidence exists. Clinical practice varies; therefore, performance of a prospective randomized clinical trial of surgical terminal filum lysis for the treatment of occult TCS is advocated.

Spina bifida occulta in functional enuresis

OBJECTIVE

To study incidence of spina bifida occulta in nocturnal enuresis cases and to compare outcome of enuresis with spina bifida occulta and enuresis without spina bifida occulta.

METHODS

Patients with enuresis divided into two groups based on X-ray lumbosacral spine. Outcome of these patients were compared on behavioral therapy.

RESULTS

Spina bifida occulta was detected in 18 out of total 48 patients. Levels of spina bifida were L5 vertebrae in 3,L5-S1 in 5,S1 in 8 and S1-S2 in 2 patients. Outcome was evaluated in 42 patients who were followed up for more than 6 months. There was no significant difference between both the groups.

CONCLUSION

Spina bifida occulta is a common finding in enuresis. Outcome of patients with spina bifida occulta is not different than the patients without spina bifida occulta.

IS SPINA BIFIDA OCCULTA ASSOCIATED WITH LOWER URINARY TRACT DYSFUNCTION IN CHILDREN?

PURPOSE

Of congenital malformations of the central nervous system 46% are abnormalities of the spinal cord, which includes spina bifida occulta. The occurrence and significance of spina bifida occulta in children with lower urinary tract and bowel dysfunction were evaluated prospectively.

MATERIALS AND METHODS

Between January 1999 and February 2001, 158 consecutive children presenting with lower urinary tract and bowel dysfunction were prospectively evaluated for associated spinal abnormalities. Plain abdominal x-ray showed either the presence or absence of fusion of the posterior elements of the lumbar and/or sacral spinous processes. Of the 158 patients 57 (36%) had spina bifida occulta (group 1) and 101 (64%) did not (group 2).

RESULTS

There was no correlation between clinical outcome in group 1 with spina bifida occulta and lower urinary tract dysfunction and the pattern of spina bifida occulta. Significant correlation was present between lower urinary tract dysfunction and the presence of spina bifida occulta on plain abdominal x-ray. No significant correlation was found between the presence of spina bifida occulta and spinal cord abnormalities by magnetic resonance imaging scan. There was no direct causal relation between the radiological finding and lower urinary tract dysfunction.

CONCLUSIONS

Children presenting with spina bifida occulta, and lower urinary tract and bowel dysfunction have normal genitourinary tracts and absent spinal cord abnormalities. Spina bifida occulta is probably a coincidental finding and its true significance in this cohort was not established.

Unexpected findings on brain and spine imaging in children

In the office practice of pediatrics, the clinical threshold for order-ing imaging studies of the brain and spine has fallen in recent years, and requests have multiplied for consultation .o assess the meaning of unexpected imaging findings. Familiarity with the most common entities that precipitate such requests allows the pediatrician to allay parental anxieties with informed preliminary counseling and to set appropriate priorities for subsequent referrals and investigations.

Bladder-anal reflex

AIMS

The purposes of this study were to evaluate the bladder-anal reflex (BAR) latency in asymptomatic women and determine the pathway of the reflex using selective anesthesia and neuromuscular block.

METHODS

Urinary incontinence, voiding dysfunction, and pelvic organ prolapse are common problems in women. Evaluation of pelvic nerve function often augments the clinical assessment of these women. Urethral-anal and clitoral-anal reflex testing have been reported as methodologies to assess patients with neurogenic disorders. A bladder-anal reflex is also obtainable but has not been reported previously in the literature. Twenty-two subjects and two patients were recruited for evaluation of the BAR.

RESULTS

This study has allowed us to estimate reference ranges for BAR latency and threshold. We defined the upper limit of these reference ranges as two standard deviations above their respective means. For the BAR latency, the upper limit of the reference range is 91 msec. Any latency value above this limit should be considered abnormal. The upper limit for the BAR threshold reference range is 37.7 mA. Lower thresholds are not thought to be clinically meaningful due to the presence of several low sensory thresholds in this asymptomatic normal population.

CONCLUSIONS

The BAR was obtainable in asymptomatic women and compatible with known anatomy and innervation of the lower urinary tract.

Pathophysiology of pelvic organ prolapse

Pelvic organ prolapse is usually caused by weakness of the pelvic diaphragm. Descent of the pelvic diaphragm places stress on the endopelvic connective tissue support system. Subsequent increases in intra-abdominal pressure result in prolapse. In the majority of cases, labor and childbirth are thought to be the primary factors responsible for pelvic neuropathies and tissue damage that predispose to the development of POP. Certain connective tissue defects, congenital defects, and operative procedures also contribute to pelvic support defects.

Magnetic resonance imaging in children with voiding dysfunction: is it indicated?

PURPOSE

We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in children with complicated voiding dysfunction and normal neuro-orthopedic examination.

MATERIALS AND METHODS

We reviewed the records of 32 consecutive children with complicated enuresis who were referred for neurosurgical evaluation, including those with a history of refractory voiding dysfunction or incontinence associated with persistent vesicoureteral reflux, encopresis, or associated leg or back pain. Nine patients were excluded from study because of urethral or anorectal anomalies, or failure to meet the inclusion criteria. Eligible for study inclusion were 23 children with a mean age of 8.9 years. Complete neurological and orthopedic examinations were normal in all patients except 1 with mild scoliosis and 1 with congenital facial palsy.

RESULTS

Urodynamic studies revealed instability in 14 cases, hypertonia in 7, hyporeflexia in 2 and detrusor-sphincter dyssynergia in 4. Skeletal abnormalities, mostly spina bifida occulta, were detected in 16 of the 23 children (70%). Spinal MRI was normal in 21 patients (91.3%), including 1 with a tethered cord and lipoma associated with a complex skeletal abnormality, and 1 with a nonprogressive, nonsurgical T7 to T9 syrinx. Only the case of lipoma required neurosurgical intervention.

CONCLUSIONS

The value of MRI is limited in children with voiding dysfunction and a normal neuro-orthopedic assessment. This study should be reserved for patients with associated neuroorthopedic findings or complex skeletal deformity on plain x-ray.

Magnetic resonance imaging in children with voiding dysfunction: is it indicated?

PURPOSE

We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in children with complicated voiding dysfunction and normal neuro-orthopedic examination.

MATERIALS AND METHODS

We reviewed the records of 32 consecutive children with complicated enuresis who were referred for neurosurgical evaluation, including those with a history of refractory voiding dysfunction or incontinence associated with persistent vesicoureteral reflux, encopresis, or associated leg or back pain. Nine patients were excluded from study because of urethral or anorectal anomalies, or failure to meet the inclusion criteria. Eligible for study inclusion were 23 children with a mean age of 8.9 years. Complete neurological and orthopedic examinations were normal in all patients except 1 with mild scoliosis and 1 with congenital facial palsy.

RESULTS

Urodynamic studies revealed instability in 14 cases, hypertonia in 7, hyporeflexia in 2 and detrusor-sphincter dyssynergia in 4. Skeletal abnormalities, mostly spina bifida occulta, were detected in 16 of the 23 children (70%). Spinal MRI was normal in 21 patients (91.3%), including 1 with a tethered cord and lipoma associated with a complex skeletal abnormality, and 1 with a nonprogressive, nonsurgical T7 to T9 syrinx. Only the case of lipoma required neurosurgical intervention.

CONCLUSIONS

The value of MRI is limited in children with voiding dysfunction and a normal neuro-orthopedic assessment. This study should be reserved for patients with associated neuroorthopedic findings or complex skeletal deformity on plain x-ray.

Cryptorchidism in boys with imperforate anus

In a retrospective study of the case reports of 136 boys who were operated on for an imperforate anus and who survived at least 18 months, cryptorchidism was the most common associated anomaly, involving 26 cases (19%). The higher the level of the anorectal malformations, the higher was the incidence of cryptorchidism. The incidence of renal and ureteric malformations and dysplasias showed a parallel tendency. The incidence of vertebral malformations and dysplasias in the T10-S5 area was low among patients with a covered anus or a perineal fistula. Cryptorchidism was found associated with urological and with T10-S5 vertebral malformations and dysplasias. Recognition of this association is probably new. The histopathological findings of testicular biopsy specimens and the location of the undescended testes in patients with an imperforate anus showed the same pattern as seen in undescended testes from patients with cryptorchidism only. These findings, together with the existing literature on the subject, indicate that further studies on the association of cryptorchidism, urological, and T10-S5 vertebral malformations and dysplasias may be very helpful toward a better understanding of cryptorchidism in general.

Significance of spina bifida occulta in children with diurnal enuresis

We reviewed retrospectively 456 patients with diurnal enuresis to determine the relationship between spina bifida occulta and attainment of continence. Of these patients 127 had undergone x-rays of the spine and 48 children (48%) had spina bifida occulta. The clinical course of these patients was compared to 79 enuretic children with normal spine films. All patients were initially treated with a timed voiding program and 28 with persistent enuresis were given anticholinergic medication. Findings on urodynamic studies were similar for both groups. Uninhibited bladder contractions were found in the majority of patients and 2 children in each group had hypertonic filling curves. Of 10 children with spina bifida occulta magnetic resonance imaging or ultrasound of the spine revealed lipoma and tethering of the cord in 1. Mean followup for both groups was 3 years. The outcome for enuretic children with spina bifida occulta was comparable to those with normal spine x-rays. The majority of patients had resolution of the enuresis with conservative management. Spinal ultrasound or magnetic resonance imaging may be warranted in those children with abnormal neurological findings on examination or hypertonic filling curves, or those who fail to respond to medical treatment. However, neurosurgical intervention to achieve continence appears necessary in only a small percentage of enuretic children with spina bifida occulta.

Tethered cord syndrome: an unusual cause of adult bladder dysfunction

Tethered cord syndrome is a complication of spinal dysraphism. The tethering of the cord does not permit the normal cranial migration of the conus within the vertebral canal and this results in neural dysfunction due to a traction neuropathy. Although this condition commonly presents in childhood, less severe degrees of tethering may remain asymptomatic until adult life. The clinical features, imaging and management of 5 adults with this condition are reviewed. Both urological and neurosurgical intervention are aimed at preservation of function as, unlike the sensorimotor deficit that commonly complicates this condition, improvement in bladder function is uncommon following cord release.