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de Almeida VC, Leite MTC, Dastoli PA, Watanabe RA, Zanon N. Recurrent tethered cord: outcome and follow-up of 20 de-thetering for symptomatic spina bifida: choort study. Childs Nerv Syst 2024:10.1007/s00381-024-06537-y. [PMID: 39017694 DOI: 10.1007/s00381-024-06537-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: 06/23/2024] [Accepted: 07/07/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE The objective of this study was to evaluate the prevalence of tethered cord among patients in the postoperative period of open and occult spina bifida. To identify warning signs for its early diagnosis, as well as outcomes after the new surgical approach. METHODS Retrospective study of patients followed at the Pediatric Neurosurgery Department of the Federal University of São Paulo with spinal dysraphism. Signs and symptoms indicating reoperation were collected, and postoperative results were classified as improved, unchanged, or worsened. RESULTS 222 medical records of patients diagnosed with spinal dysraphism were evaluated. Symptomatic Tethered Cord Syndrome (STCS) was identified in 30 patients (13.51%), with clinical manifestations related to orthopedic deformities (66.7%), neurological deficits (56.7%), urological dysfunction (50%), and intestinal dysfunction (40%). 20 cases underwent surgery for tethered cord release. The mean age at the time of surgery was 7.7 ± 4.9 years, with 13 female patients (65%). In the postoperative evaluation, improvement in low back pain (90.9%), urological pattern, and urinary tract infection episodes (45.4%) were particularly noteworthy. 3 patients (33.3%) with constipation showed improvement, and one worsened (11.1%). Improvement in ambulation was seen in two cases (16.7%). Low back pain was the first symptom to improve after surgery, with an average time of 1.3 months, followed by changes in the urological pattern at 15.6 months. Improvement in constipation was observed in the first month in 2 cases (66.7%), positive changes in ambulation were observed around 7 months after surgery, and only one case showed improvement in clubfoot correction. CONCLUSIONS The prevalence of tethered cord recurrence after primary correction surgery for open or occult neural tube closure defects was similar to that found in the literature. The results were encouraging, with good postoperative evolution of patients, especially in the improvement of low back pain and urological symptoms.
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Affiliation(s)
| | | | | | | | - Nelci Zanon
- Department of Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
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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 PMCID: PMC10972940 DOI: 10.1007/s00381-023-06246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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Baskurt O, Hicdonmez T, Gazioglu MN. Aberrant Dorsal Nerve Root as a Concomitant Cause of Spinal Cord Tethering Associated with a Dorsal Type Lipomyelomeningocele in a Child With Caudal Agenesis. Niger J Clin Pract 2024; 27:537-540. [PMID: 38679779 DOI: 10.4103/njcp.njcp_838_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/29/2024] [Indexed: 05/01/2024]
Abstract
ABSTRACT Tethered cord syndrome is a neurological disorder closely associated with congenital spinal dysraphism. Aberrant dorsal nerve roots may be one of the possible and relatively rare tethering pathologies, especially in the complex form of occult spinal dysraphism such as caudal regression syndrome or split cord malformation. We report an illustrative case of caudal regression syndrome with spinal cord tethering due to a combination of a contiguous bundle of an aberrant dorsal nerve root, and a dorsal-type lipomyelomeningocele, with a thickened filum terminale treated with microneurosurgical untethering.
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Affiliation(s)
- O Baskurt
- Department of Neurosurgery, Istinye University Faculty of Medicine, Istanbul, Türkiye
- Department of Neurosurgery, Liv Hospital Vadistanbul, Istanbul, Türkiye
| | - T Hicdonmez
- Department of Neurosurgery, Istinye University Faculty of Medicine, Istanbul, Türkiye
- Department of Neurosurgery, Liv Hospital Vadistanbul, Istanbul, Türkiye
| | - M N Gazioglu
- Department of Neurosurgery, Istinye University Faculty of Medicine, Istanbul, Türkiye
- Department of Neurosurgery, Liv Hospital Vadistanbul, Istanbul, Türkiye
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Jiao L, Wang S, Yang X, Ma JX, Zheng L, Wang H, Xiang LB, Yu HL, Chen Y. Current Global Research Trends of Tethered Cord Syndrome Surgery: A Scientometric and Visual Analysis. World Neurosurg 2024; 183:206-213. [PMID: 38143026 DOI: 10.1016/j.wneu.2023.12.107] [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: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
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.
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Affiliation(s)
- Liang Jiao
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Shuang Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiao Yang
- Department of Anesthesiology, The Air Force Hospital of Northern Theater PLA, Shenyang, China
| | - Jun-Xiong Ma
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Liang Zheng
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Hong Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Liang-Bi Xiang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Hai-Long Yu
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Chen
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China.
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5
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Kerensky MJ, Paul A, Routkevitch D, Hersh AM, Kempski Leadingham KM, Davidar AD, Judy BF, Punnoose J, Williams A, Kumar A, Lehner K, Smith B, Son JK, Azadi JR, Shekhar H, Mercado-Shekhar KP, Thakor NV, Theodore N, Manbachi A. Tethered spinal cord tension assessed via ultrasound elastography in computational and intraoperative human studies. COMMUNICATIONS MEDICINE 2024; 4:4. [PMID: 38182729 PMCID: PMC10770351 DOI: 10.1038/s43856-023-00430-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 12/19/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Tension in the spinal cord is a trademark of tethered cord syndrome. Unfortunately, existing tests cannot quantify tension across the bulk of the cord, making the diagnostic evaluation of stretch ambiguous. A potential non-destructive metric for spinal cord tension is ultrasound-derived shear wave velocity (SWV). The velocity is sensitive to tissue elasticity and boundary conditions including strain. We use the term Ultrasound Tensography to describe the acoustic evaluation of tension with SWV. METHODS Our solution Tethered cord Assessment with Ultrasound Tensography (TAUT) was utilized in three sub-studies: finite element simulations, a cadaveric benchtop validation, and a neurosurgical case series. The simulation computed SWV for given tensile forces. The cadaveric model with induced tension validated the SWV-tension relationship. Lastly, SWV was measured intraoperatively in patients diagnosed with tethered cords who underwent treatment (spinal column shortening). The surgery alleviates tension by decreasing the vertebral column length. RESULTS Here we observe a strong linear relationship between tension and squared SWV across the preclinical sub-studies. Higher tension induces faster shear waves in the simulation (R2 = 0.984) and cadaveric (R2 = 0.951) models. The SWV decreases in all neurosurgical procedures (p < 0.001). Moreover, TAUT has a c-statistic of 0.962 (0.92-1.00), detecting all tethered cords. CONCLUSIONS This study presents a physical, clinical metric of spinal cord tension. Strong agreement among computational, cadaveric, and clinical studies demonstrates the utility of ultrasound-induced SWV for quantitative intraoperative feedback. This technology is positioned to enhance tethered cord diagnosis, treatment, and postoperative monitoring as it differentiates stretched from healthy cords.
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Affiliation(s)
- Max J Kerensky
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abhijit Paul
- Discipline of Biological Engineering, Indian Institute of Technology Gandhinagar, Gujarat, India
| | - Denis Routkevitch
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew M Hersh
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelley M Kempski Leadingham
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Daniel Davidar
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua Punnoose
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Autumn Williams
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Avisha Kumar
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Kurt Lehner
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Beth Smith
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer K Son
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Javad R Azadi
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Himanshu Shekhar
- Discipline of Electrical Engineering, Indian Institute of Technology Gandhinagar, Gujarat, India
| | - Karla P Mercado-Shekhar
- Discipline of Biological Engineering, Indian Institute of Technology Gandhinagar, Gujarat, India
| | - Nitish V Thakor
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amir Manbachi
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA.
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Hara T, Ohara Y, Kondo A. Diagnosis and Management of Tethered Cord Syndrome. Adv Tech Stand Neurosurg 2024; 49:35-50. [PMID: 38700679 DOI: 10.1007/978-3-031-42398-7_3] [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] [Indexed: 06/01/2024]
Abstract
Tethered cord syndrome is a condition in which the spinal cord is tethered by pathological structures such as a tight filum terminale, intradural lipomas with or without a connecting extradural component, intradural fibrous adhesions, diastematomyelia, and neural placode adhesions following closure of a myelomeningocele.It usually occurs in childhood and adolescence as the spine grows in length, but it can also develop in adulthood. Symptoms of tethered cord syndrome are slowly progressive and varied. Incorrect diagnosis and inappropriate treatment may be provided if the physician lacks knowledge and understanding of this disease.This chapter aims to describe the pathophysiology, syndromes, diagnostic imaging, surgical treatment, and prognosis of tethered cord syndrome to enhance the understanding of this condition.
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Affiliation(s)
- Takeshi Hara
- Department of Neurosurgery, Spine and Spinal Cord Center, Juntendo University School of Medicine, Tokyo, Japan.
| | - Yukoh Ohara
- Department of Neurosurgery, Spine and Spinal Cord Center, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Spine and Spinal Cord Center, Juntendo University School of Medicine, Tokyo, Japan
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Gajagowni S, Mazuru-Witten D, Hegstrom J, Goodman J, Vachharajani AJ. Ultrasound-Guided Prospective Screening for Spinal Dysraphism in Offspring of Mothers With Pregestational Diabetes: A Pilot Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2867-2872. [PMID: 37792458 DOI: 10.1002/jum.16327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023]
Abstract
AIM Determine the utility of prospective spinal ultrasound in infants of mothers with pregestational diabetes (PGDM) for the diagnosis of closed spinal dysraphism (SDs). METHODS This prospective observational pilot study was completed at a tertiary care center between May 1, 2020 and December 30, 2022. Infants born to mothers with PGDM and with normal spinal physical examinations were included. A total of 25 mother-infant dyads were enrolled in the study and prospectively screened with spinal ultrasound. The study was registered on ClinicalTrials.gov (Identifier-NCT05033275). RESULTS Twenty-five spinal ultrasounds were performed over the course of this study with three (8%) resulting in abnormal findings that required further imaging. Follow-up with magnetic resonance imaging found one case of tethered cord syndrome. CONCLUSION Prospective screening in infants of mothers with PGDM found one case of tethered cord syndrome. This finding suggests that risk stratified screening of mothers with diabetes might be a reasonable approach to care.
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Affiliation(s)
| | - Danielle Mazuru-Witten
- Department of Radiology, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Jessica Hegstrom
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Jean Goodman
- Department of Obstetrics and Gynecology, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Akshaya J Vachharajani
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Missouri, School of Medicine, Columbia, Missouri, USA
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Morota N, Ihara S, Inukai M, Kuroha S. Ventral anchoring of the conus medullaris: a new surgical technique preventing the radiographic recurrence of retethering after surgery for tethered spinal cord. Childs Nerv Syst 2023; 39:3147-3154. [PMID: 37115276 DOI: 10.1007/s00381-023-05972-7] [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: 12/31/2022] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Retethering is not an unusual operation for a congenital lumbosacral dysraphic spinal lesion. The present study aimed to assess a new surgical technique for preventing retethering. SURGICAL TECHNIQUE After untethering the spinal cord, the pia mater or scar tissue at the caudal end of the conus medullaris is anchored to the ventral dura mater loosely using 8-0 thread, and the dura mater is closed directly. This technique is called ventral anchoring. RESULTS Ventral anchoring was performed in 15 patients (aged 5 to 37 years old, average age: 12.1 years old) between 2014 and 2021. All but one patient showed improvement or stabilization of the preoperative symptoms. No complication directly related to the procedure was observed. Postoperative MRI demonstrated that the dorsal subarachnoid space was restored in 14 patients but was undetectable or absent in three patients on follow-up MRI. No patients have experienced a recurrence of the tethered cord syndrome during the follow-up period. CONCLUSION Ventral anchoring is effective for restoring the dorsal subarachnoid space after untethering the spinal cord. This preliminary study suggested that ventral anchoring has the potential to prevent the postoperative radiographic recurrence of tethered spinal cord in patients with a congenital lumbosacral dysraphic spinal lesion.
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Affiliation(s)
- N Morota
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan.
| | - S Ihara
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - M Inukai
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - S Kuroha
- Department of Neurosurgery, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
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Spoor JKH, Kik CC, van Veelen MLC, Dirven C, Miller JL, Groves ML, DeKoninck PLJ, Baschat AA, Eggink AJ. Potential higher risk of tethered spinal cord in children after prenatal surgery for myelomeningocele: A systematic review and meta-analysis. PLoS One 2023; 18:e0287175. [PMID: 37379312 DOI: 10.1371/journal.pone.0287175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
INTRODUCTION We performed a systematic review and meta-analysis on the incidence of secondary tethered spinal cord (TSC) between prenatal and postnatal closure in patients with MMC. The objectives was to understand the incidence of secondary TSC after prenatal surgery for MMC compared to postnatal surgery for MMC. MATERIAL AND METHODS On May 4, 2023, a systematic search was conducted in Medline, Embase, and the Cochrane Library to gather relevant data. Primary studies focusing on repair type, lesion level, and TSC were included, while non-English or non-Dutch reports, case reports, conference abstracts, editorials, letters, comments, and animal studies were excluded. Two reviewers assessed the included studies for bias risk, following PRISMA guidelines. TSC frequency in MMC closure types was determined, and the relationship between TSC occurrence and closure technique was analyzed using relative risk and Fisher's exact test. Subgroup analysis revealed relative risk differences based on study designs and follow-up periods. A total of ten studies, involving 2,724 patients, were assessed. Among them, 2,293 patients underwent postnatal closure, while 431 received prenatal closure for the MMC defect. In the prenatal closure group, TSC occurred in 21.6% (n = 93), compared to 18.8% (n = 432) in the postnatal closure group. The relative risk (RR) of TSC in patients with prenatal MMC closure versus postnatal MMC closure was 1.145 (95%CI 0.939 to 1.398). Fisher's exact test indicated a statistically non-significant association (p = 0.106) between TSC and closure technique. When considering only RCT and controlled cohort studies, the overall RR for TSC was 1.308 (95%CI 1.007 to 1.698) with a non-significant association (p = .053). For studies focusing on children up until early puberty (maximum 12 years follow-up), the RR for tethering was 1.104 (95%CI 0.876 to 1.391), with a non-significant association (p = 0.409). CONCLUSION AND DISCUSSION This review found no significant increase in relative risk of TSC between prenatal and postnatal closure in MMC patients, but a trend of increased TSC in the prenatal group. More long-term data on TSC after fetal closure is needed for better counseling and outcomes in MMC.
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Affiliation(s)
- Jochem K H Spoor
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Charlotte C Kik
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marie-Lise C van Veelen
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clemens Dirven
- Department of Pediatric Neurosurgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynaecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynaecology & Obstetrics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Alex J Eggink
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
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Pellegrino C, Forlini V, Lena F, Capitanucci ML, Diomedi Camassei F, Castelli E, Mosiello G. Onabotulinum Toxin A Intradetrusor Injections in Children with Neurogenic Lower Urinary Tract Dysfunction: Long-Term Histological Effects on the Bladder Wall. Biomedicines 2023; 11:biomedicines11051300. [PMID: 37238971 DOI: 10.3390/biomedicines11051300] [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: 03/27/2023] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND In the last twenty-five years, Onabotulinum Toxin A (BTX-A) has gained increasing popularity for neurogenic lower urinary tract dysfunction (NLUTD) treatment. To maintain its efficacy, repeated BTX-A intradetrusor injections are required over time, with unknown effects on the bladder wall in children. The aim of this paper is to report long-term effects on the bladder wall in children treated with BTX-A. METHODS Children with NLUTD not responsive to anticholinergics were treated with BTX-A, according to our protocol, with bladder wall control using endoscopic cold-cup biopsy. Specimens were evaluated considering edema, chronic inflammation, and fibrosis. RESULTS Of the 230 patients treated from 1997 to 2022, we considered only specimens obtained in patients who had received ≥5 treatments (36 children), considered as the threshold to evaluate clinical effectiveness on long-term treatment with BTX-A. Most of them had congenital NLUTD (25 patients) and detrusor overactivity (27 patients). In all, increased edema and chronic inflammation with reduced fibrosis over time was reported; these data were not statistically significant. No difference was observed between patients with congenital and acquired diseases. CONCLUSIONS Repeated intradetrusor BTX-A injections are not related to significant histological alterations in children, similarly with adults, and repeated injections could be considered safe.
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Affiliation(s)
- Chiara Pellegrino
- Division of Neuro-Urology, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 ERN eUROGEN Affiliated Center, 00118 Rome, Italy
| | - Valentina Forlini
- Division of Neuro-Urology, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 ERN eUROGEN Affiliated Center, 00118 Rome, Italy
- Pediatric Surgery Division, University of Genova, via Balbi 5, 16126 Genoa, Italy
| | - Federica Lena
- Division of Neuro-Urology, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 ERN eUROGEN Affiliated Center, 00118 Rome, Italy
- Pediatric Surgery Division, University of Genova, via Balbi 5, 16126 Genoa, Italy
| | - Maria Luisa Capitanucci
- Division of Neuro-Urology, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 ERN eUROGEN Affiliated Center, 00118 Rome, Italy
| | | | - Enrico Castelli
- Pediatric Neurorehabilitation, Bambino Gesù Children's Hospital, 00118 Rome, Italy
| | - Giovanni Mosiello
- Division of Neuro-Urology, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio, 4, 00165 ERN eUROGEN Affiliated Center, 00118 Rome, Italy
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11
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Jiao L, Yang X, Wang S, Ma JX, Zheng L, Wang H, Yu HL, Chen Y. Dekyphosis operation combined with limited osteotomy to treat the symptomatic adult tethered cord syndrome with complicated malformations: A case report. Medicine (Baltimore) 2023; 102:e33600. [PMID: 37115079 PMCID: PMC10145974 DOI: 10.1097/md.0000000000033600] [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: 03/10/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Liang Jiao
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Xiao Yang
- Department of Anesthesiology, The Air Force Hospital of Northern Theater PLA, Dadong District, Shenyang, China
| | - Shuang Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Jun-Xiong Ma
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Liang Zheng
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Hong Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Hai-Long Yu
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Yu Chen
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
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12
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de Beaufort CMC, Groenveld JC, Mackay TM, Slot KM, de Beer SA, de Jong JR, van Schuppen J, McDonald CJ, Bakker DP, van den Berg E, Kuijper CF, Gorter RR. Spinal cord anomalies in children with anorectal malformations: a retrospective cohort study. Pediatr Surg Int 2023; 39:153. [PMID: 36934393 PMCID: PMC10025224 DOI: 10.1007/s00383-023-05440-y] [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] [Accepted: 03/10/2023] [Indexed: 03/20/2023]
Abstract
PURPOSE First, to assess the number of spinal cord anomalies (SCA), specifically tethered spinal cord (TSC) in patients with anorectal malformations (ARM), identified with spinal cord imaging (i.e. spinal cord US and/or MRI). Second, to report outcomes after TSC treatment. METHODS A retrospective mono-center study was performed. All ARM patients born between January 2000 and December 2021 were included. Screening for SCA consisted of spinal cord US and/or MRI. Radiology reports were scored on presence of SCA. Data were presented with descriptive statistics. RESULTS In total, 254 patients were eligible for inclusion, of whom 234 (92.1%) underwent spinal cord imaging. In total, 52 (22.2%) patients had a SCA, diagnosed with US (n = 20, 38.5%), MRI (n = 10, 19.2%), or both US and MRI (n = 22, 42.3%), of whom 12 (23.5%) with simple, 27 (52.7%) intermediate, and 12 (23.5%) complex ARM types. TSC was identified in 19 patients (8.1%), of whom 4 (21.1%) underwent uncomplicated neurosurgical intervention. CONCLUSIONS SCA were present in 22% of ARM patients both in simple, as well as more complex ARM types. TSC was present in 19 patients with SCA, of whom 4 underwent uncomplicated neurosurgical intervention. Therefore, screening for SCA seems to be important for all ARM patients, regardless of ARM type. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cunera M C de Beaufort
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam UMC, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands.
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Julia C Groenveld
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tara M Mackay
- Amsterdam UMC, Department of Surgery, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - K Mariam Slot
- Amsterdam UMC, Department of Neurosurgery, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Sjoerd A de Beer
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Justin R de Jong
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Joost van Schuppen
- Amsterdam UMC, Department of Radiology and Nuclear Medicine, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Carola J McDonald
- Amsterdam UMC, Department of Pediatric Neurology, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Dewi P Bakker
- Amsterdam UMC, Department of Pediatric Neurology, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Elske van den Berg
- Amsterdam UMC, Department of Pediatric Neurology, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Caroline F Kuijper
- Department of Pediatric Urology, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Ramon R Gorter
- Department of Pediatric Surgery, Emma Children's Hospital Amsterdam UMC, Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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13
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Shin HI, Wang KC, Lee JY, Kim KH, Shin HI. Electrodiagnostic findings of retethering in children with spinal dysraphism. Acta Neurochir (Wien) 2023; 165:915-925. [PMID: 36862215 DOI: 10.1007/s00701-023-05539-0] [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: 12/28/2022] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Retethering of the cord can occur after the initial untethering surgery. Typical neurological manifestations indicative of cord tethering are often difficult to determine in pediatric patients. Patients who had a primary untethering operation are likely to present with some degree of neurological deficits from a previous tethering event, and urodynamic studies (UDSs) and spine images are frequently abnormal. Therefore, more objective tools to detect retethering are needed. This study sought to delineate the characteristics of EDS of retethering, and therefore, could support the diagnosis of retethering. METHODS Among 692 subjects who had an untethering operation, data from 93 subjects who had been suspected of retethering clinically were retrospectively extracted. The subjects were divided into two groups, a retethered group, and a non-progression group, according to whether or not surgical interventions had been performed. Two consecutive EDSs, clinical findings, spine magnetic resonance imaging scans, and UDSs before the development of new tethering symptoms were reviewed and compared. RESULTS In the electromyography (EMG) study, the appearance of abnormal spontaneous activity (ASA) in new muscles was prominent in the retethered group (p < 0.01). The loss of ASA was more pronounced in the non-progression group (p < 0.01). Specificity and sensitivity of EMG for retethering were 80.4 and 56.5%, respectively. In the nerve conduction study, the two groups did not show differences. The size of fibrillation potential was not different between the groups. CONCLUSIONS To provide support for a clinician's decision on retethering, EDS could be an advantageous tool with high specificity when the results are compared to previous EDS results. Routine follow-up EDS post-operatively is recommended as a baseline for comparison at the time when retethering is clinically suspected.
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Affiliation(s)
- Hyun Iee Shin
- Department of Rehabilitation Medicine, College of Medicine, Chung-Ang University, Chung-Ang University Hospital, 102 Heukseok-Ro, Dongjak-Gu, Seoul, 06973, Republic of Korea
| | - Kyu-Chang Wang
- Neuro-Oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Kyounggi-do, 10408, Republic of Korea
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.,Department of Anatomy and Cell Biology, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno‑Gu, Seoul, 03080, Republic of Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, College of Medicine, Seoul National University, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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14
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Rafiee F, Mehan WA, Rincon S, Rohatgi S, Rapalino O, Buch K. Diagnostic Utility of 3D Gradient-Echo MR Imaging Sequences through the Filum Compared with Spin-Echo T1 in Children with Concern for Tethered Cord. AJNR Am J Neuroradiol 2023; 44:323-327. [PMID: 36797030 PMCID: PMC10187807 DOI: 10.3174/ajnr.a7791] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/09/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND AND PURPOSE Fatty intrathecal lesions are a cause of tethered cord, and detection of these on spinal MR imaging is paramount. Conventional T1 FSE sequences are the mainstay of detecting fatty elements; however, 3D gradient-echo MR images, volumetric interpolated breath-hold examination/liver acquisition with volume acceleration (VIBE/LAVA), are popular, given the increased motion resistance. We sought to evaluate the diagnostic accuracy of VIBE/LAVA compared with T1 FSE for detection of fatty intrathecal lesions. MATERIALS AND METHODS In this retrospective, institutional review board-approved study, 479 consecutive pediatric spine MRIs obtained to evaluate cord tethering between January 2016 and April 2022 were reviewed. Inclusion criteria were patients who were 20 years of age or younger who underwent spine MRIs containing both axial T1 FSE and VIBE/LAVA sequences of the lumbar spine. The presence or absence of fatty intrathecal lesions was recorded for each sequence. If fatty intrathecal lesions were present, anterior-posterior and transverse dimensions were recorded. VIBE/LAVA and T1 FSE sequences were evaluated on 2 separate occasions (VIBE/LAVAs first followed by T1 FSE several weeks later) to minimize bias. Basic descriptive statistics compared fatty intrathecal lesion sizes on T1 FSEs and VIBE/LAVAs. Receiver operating characteristic curves were used to determine minimal fatty intrathecal lesion size detectable by VIBE/LAVA. RESULTS Sixty-six patients were included, with 22 having fatty intrathecal lesions (mean age, 7.2 years). T1 FSE sequences revealed fatty intrathecal lesions in 21/22 cases (95%); however, fatty intrathecal lesions on VIBE/LAVA were detected in 12/22 patients (55%). Mean anterior-posterior and transverse dimensions of fatty intrathecal lesions measured larger on T1 FSE compared with VIBE/LAVA sequences (5.4 × 5.0 mm versus 1.5 × 1.6 mm, respectively; P values = .039 anterior-posterior; .027 transverse). CONCLUSIONS While T1 3D gradient-echo MR images may have decreased the acquisition time and are more motion-resistant than conventional T1 FSE sequences, they are less sensitive and may miss small fatty intrathecal lesions.
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Affiliation(s)
- F Rafiee
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - W A Mehan
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Rincon
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Rohatgi
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - O Rapalino
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - K Buch
- From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Mualem W, Nathani KR, Durrani S, Zamanian C, Ghaith AK, Michalopoulos GD, Rotter J, Daniels D, Bydon M. Utilizing pre- and postoperative radiological parameters to predict surgical outcomes following untethering for tethered cord syndrome in a pediatric population. J Neurosurg Pediatr 2023; 31:159-168. [PMID: 36461831 DOI: 10.3171/2022.10.peds22459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Tethered cord syndrome (TCS) can lead to significant downstream neurological deficits including gait deterioration, incontinence, and often unexplained chronic low-back pain. Surgical intervention may relieve symptoms, but there are no defined radiological parameters associated with surgical outcomes and functional status. The authors aimed to define pre- and postoperative radiological parameters for assessing surgical outcomes in TCS. METHODS The authors performed a single-center retrospective review of all pediatric patients treated for TCS between 2016 and 2021. Patient baseline characteristics and operative metrics included age, sex, level of conus, level of procedure, tethering pathology, symptoms at presentation, complications, improvement of symptoms, and reoperation rate. MRI measurements included pre- and postoperative anterior canal distance (ACD) and bending angle (BA). RESULTS Thirty-three pediatric patients were identified who underwent untethering of the spinal cord and had pre- and postoperative MRI between 2016 and 2021. The mean patient age was 5.64 ± 5.33 years. Twenty patients (60.60%) were female. Regarding the site of untethering, 31 procedures (93.93%) were performed at the lumbosacral region and 2 (6.06%) were performed at the thoracolumbar region. The conus medullaris was found above L3 in 21.21% of patients. Postoperatively, 18.18% of patients experienced complications, 48.48% showed improvement in their symptoms, and 48.48% were equivocal or had persistent symptoms. The mean preoperative ACD0 (measured from the posterior vertebral body margin [middle] to the anterior margin of the conus medullaris) was 6.15 ± 3.18 mm, the postoperative ACD0 was 2.25 ± 2.72 mm, and the average change in ACD0 was -0.90 ± 1.31 mm. The mean preoperative BA was 26.00° ± 11.56°, the mean postoperative BA was 15.92° ± 9.81°, and the average change in BA was -10.08° ± 8.80°. An optimal cutoff value for preoperative BA to predict reoperation in pediatric patients with complex TCS undergoing surgery was ≥ 31.70° (area under the curve = 0.83). CONCLUSIONS In surgically treated patients with TCS, certain preoperative radiological parameters may be important in predicting postoperative surgical outcomes; these parameters can be evaluated and reported to indicate patients at high risk for complications. Further prospective multicenter research is warranted to offer robust evidence of association of patient outcomes with preoperative radiological parameters in TCS.
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Affiliation(s)
- William Mualem
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karim Rizwan Nathani
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sulaman Durrani
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cameron Zamanian
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Abdul Karim Ghaith
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Giorgos D Michalopoulos
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Juliana Rotter
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - David Daniels
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory and
- 2Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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16
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Jing B, Zhang H, Sun Y. Prenatal assessment and pregnancy outcomes of foetal low-lying conus medullaris using 3D ultrasound. BMC Pregnancy Childbirth 2022; 22:961. [PMID: 36564726 PMCID: PMC9783809 DOI: 10.1186/s12884-022-05244-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study aims to follow up on low-lying conus medullaris (CM) cases and explore the correlation between the CM location and the final prognosis. METHODS: We retrospectively collected 37 cases diagnosed with low-lying CM during pregnancy in the Peking University First Hospital from January 2019 to December 2020. The location of CM was confirmed by 3D ultrasonography, and clinical data, including postnatal outcomes, were recorded. When the conus medullaris was below L3 (excluding L3), it was diagnosed as low-lying conus medullaris, regardless of gestational age. The short-term postnatal outcome included assessment of symptoms and signs of motor and sensory neuron dysfunction. RESULTS The average gestational weeks of low-lying diagnosis was between 23 and 24 weeks. Among 37 cases, nine (24.3%) were complicated with spine dysraphism (3 cases of open spina bifida, 6 cases of tethered cord syndrome). Apart from 7 cases of pregnancy termination, the remaining 30 live births had a good prognosis in the short term, though 5 out of 6 cases of tethered cord syndrome underwent surgical release. The mean location of cases of open spinal dysraphism (n = 3) and those of closed dysraphism/tethered cord syndrome (n = 6) was at Lumber vertebra 5 (L5) and between L5 and Sacral vertebra 1 (S1), respectively, which showed statistical significance compared with the postnatally normal group. When we set Lumber 4.25 as the cut-off value to predict the diagnosis of spine dysraphism (mainly involving open spinal dysraphism and closed spinal dysraphism/tethered cord syndrome), the sensitivity was 66.7. At the same time, the specificity was 96%, along with the area under the curve (AUC) at 0.877. CONCLUSION The second trimester finding of low CM is associated with spinal defects, mainly open spinal dysraphism and closed spinal dysraphism/tethered cord syndrome. Careful assessment of the fetal spine should be considered especially when the location of CM is lower than L4.
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Affiliation(s)
- Baihua Jing
- grid.411472.50000 0004 1764 1621The Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, China
| | - Huijing Zhang
- grid.411472.50000 0004 1764 1621The Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, China
| | - Yu Sun
- grid.411472.50000 0004 1764 1621The Department of Obstetrics and Gynaecology, Peking University First Hospital, Beijing, China
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17
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Elsabaa A, Mahmoud MA, Nosseir M, Mahmoud MWS, Aziz MM. Does early tethered cord release in occult spinal dysraphism improve urological outcomes? A systematic review. EGYPTIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1186/s41984-022-00177-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Introduction
Occult spinal dysraphism involves a wide range of congenital anomalies, e.g., lipoma, Lipomeningomyelocele, congenital dermal sinus, etc. Occult spinal dysraphism also may present with a wide spectrum of clinical manifestations and radiological findings, i.e., it ranges from asymptomatic patients that are accidentally discovered to low lying conus with neurological, skeletal and urological manifestations. Even though neurosurgeons are well-aware of neurological presentations that indicate surgical intervention in children with occult spinal dysraphism, urological symptoms may present some controversy in management. This review aims to discuss urological outcomes of detethering as regarding time of intervention, improvement of the urological symptoms after detethering, and the role of urodynamics preoperatively and during follow-up.
Methodology
An online search of the literature was done including studies in English language from 1990 to January 2022. Included studies were analytical with well conducted descriptive nature of acceptable quality (at least level 3 evidence). Patient characteristics included both male and female children and adolescents, up to 19 years old who presented with clinical and/or radiological evidence of tethering of the spinal cord. Most studies that were included had availability of urodynamics. A total of 15 studies were included involving 633 patients. Meningomyelocele (MMC) and other spina bifida operta cases are excluded.
Results
Results of all studies were collected and mean age of studies was gathered and plotted on a chart in relation to urological outcome and urodynamic improvement. Most results favored early detethering; however, many factors were found to affect the inverse proportion curve of age with clinical improvement or urodynamics. For example, studies that included secondary tethered cord showed poorer results than results that included primary tethered cord only, preoperative severity of urological symptoms (more severe symptoms were associated with irreversible poor outcomes), and preoperative urodynamic parameters.
Conclusion
The management of tethered cord syndrome and occult spinal dysraphism remains controversial. There is lack of class 1 evidence regarding tethered cord release surgery in occult spinal dysraphism. Heterogenicity of pathology, symptomatology and radiology make the randomization of such sample size difficult. The outcomes of surgical detethering are therefore multifactorial. A large sample of prospective randomized controlled studies addressing each factor, e.g., age, severity of symptoms, preoperative urodynamic parameters, is recommended in order to evaluate the impact of each factor on outcome.
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18
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Marathe N, Lohkamp LN, Fehlings MG. Spinal manifestations of Ehlers-Danlos syndrome: a scoping review. J Neurosurg Spine 2022; 37:783-793. [PMID: 35986728 DOI: 10.3171/2022.6.spine211011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since its initial description, the definition of Ehlers-Danlos syndrome (EDS) has notably changed. At present, it broadly refers to disorders of the connective tissue that are heritable and have similar features including joint hypermobility, dermal dysplasia, and vascular as well as internal organ fragility. There has been no comprehensive review of spinal manifestations of EDS in the recent literature. That has led to controversies in management protocols of this so-called orphan disease. METHODS The authors used the latest version of the EDS classification from 2017, in which 13 subtypes were recognized. EDS has 19 different causal genes, mainly associated with collagen synthesis. Of these, 5 subtypes have associated spinal manifestations. RESULTS Some of the spinal pathologies associated with EDS include Chiari malformation, craniocervical instability, kyphoscoliosis, segmental instability and kyphosis, spontaneous CSF leaks, Tarlov cyst syndrome, tethered cord, and problems associated with wound healing. Here, the authors briefly discuss the demographics, etiology, pathophysiology, clinical features, management strategies, and directions for further research for each of these manifestations. CONCLUSIONS EDS belongs to the group of orphan diseases, with the total patient population being below 200,000. Further research on spinal manifestations of EDS is the need of the hour to establish clinical practice guidelines and close the significant knowledge gaps that currently exist.
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Affiliation(s)
- Nandan Marathe
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and
| | - Laura-Nanna Lohkamp
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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19
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Kunes J, Quan T, Iyer R, Fano AN, Matsumoto H, Erickson M, McCarthy R, Brockmeyer D, Anderson RCE, Vitale MG. Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis. Spine Deform 2022; 10:1473-1480. [PMID: 35821353 DOI: 10.1007/s43390-022-00550-4] [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: 04/18/2022] [Accepted: 06/25/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE In patients with early onset scoliosis (EOS) and intraspinal anomalies, surgery may be necessary for both the tethered spinal cord (TSC) and spinal deformity. The purpose of this study was to determine if there is a difference in complications when TSC release and surgery for spinal deformity correction (SDC) are performed separately compared simultaneously. METHODS EOS patients with TSC who underwent detethering and SDC surgeries were identified through a multicenter registry. Patients were stratified into two groups. The simultaneous cohort consisted of patients receiving both detethering and SDC surgeries in a single anesthetic event on the same day, and the staged cohort consisted of patients undergoing detethering and SDC on two separate occasions. Postoperative complications up to 180 days for either surgery were assessed. RESULTS Twenty five (65.8%) patients were staged and 13 (34.2%) underwent a simultaneous approach. Percent curve correction following SDC surgery did not significantly differ between the groups (p = 0.36). Within 90 days postoperatively, 16 complications in 11 patients (44.0%) occurred in the staged group, whereas no complications occurred in the simultaneous cohort (p = 0.006). From 90-days to 180-days postoperatively, 4 additional complications in 3 patients (12.0%) occurred in the staged group, with no complications reported in the same timeframe for the simultaneous cohort. CONCLUSION To our knowledge, this is the largest multicenter comparative study to date, and it suggests that a simultaneous approach can be performed safely for EOS patients undergoing detethering and SDC surgeries, with a potentially lower risk profile than the traditional staged approach to these pathologies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jennifer Kunes
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, ATTN: Theodore Quan, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA
| | - Theodore Quan
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, ATTN: Theodore Quan, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA.
| | - Rajiv Iyer
- Department of Neurosurgery, Intermountain Primary Children's Hospital, University of Utah, Salt Lake City, UT, 84113, USA
| | - Adam N Fano
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, ATTN: Theodore Quan, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA
| | - Hiroko Matsumoto
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, ATTN: Theodore Quan, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Mark Erickson
- Department of Orthopaedics, Children's Hospital Colorado, Aurora, CO, 80045, USA
| | - Richard McCarthy
- Department of Orthopaedics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, 72205, USA
| | - Douglas Brockmeyer
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84113, USA
| | - Richard C E Anderson
- New York University, Hassenfeld Children's Hospital at NYU Langone, New York, NY, 10016, USA
| | - Michael G Vitale
- Department of Orthopedic Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Irving Medical Center, ATTN: Theodore Quan, 3959 Broadway, CHONY 8-N, New York, NY, 10032, USA
- Division of Pediatric Orthopaedic Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, 10032, USA
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Muacevic A, Adler JR, Zhang YP, Shields CB. Importance of Electrodiagnostic Testing Prior to a Tethered Cord Release in a Patient with Overlapping Symptoms of Charcot-Marie-Tooth Disease. Cureus 2022; 14:e32076. [PMID: 36600859 PMCID: PMC9803868 DOI: 10.7759/cureus.32076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2022] [Indexed: 12/03/2022] Open
Abstract
Charcot-Marie-Tooth (CMT) disease is the most common inherited neuromuscular disorder causing a symmetric, slowly progressive distal neuropathy of the legs and arms. Tethered cord syndrome (TCS) encompasses a constellation of neurological, gastrointestinal, musculoskeletal, and urinary abnormalities resulting from spinal cord traction. The signs and symptoms of CMT and TCS may be very similar. Electrodiagnostic (EDX) studies are crucial in differentiating between these two conditions. We describe a 20-year-old woman with a history of low back pain, right leg tingling, and difficulty in walking. She experienced bowel and urinary incontinence 11 years earlier as well as back pain, in-toeing gait, and difficulties with balance and coordination. Urodynamic studies and cervical, thoracic, and lumbar magnetic resonance imaging (MRI) were normal, with the latter demonstrating the tip of the conus medullaris in the normal position at the L1-2 interspace and the filum terminale demonstrating no thickening or fatty infiltration. Despite the absence of radiological evidence of TCS, she underwent a tethered cord release (TCR) with improvement of the pain postoperatively. Two years later, the back pain recurred with increasing pain, paresthesia, and weakness of the lower extremities with frequent trip and fall episodes. EDX studies of the lower extremities were requested. Clinical findings included weakness of flexion and extension of the toes as well as dorsiflexors of the ankles bilaterally. The knee and ankle reflexes were absent bilaterally. EDX testing of the lower extremities were non-diagnostic due to loss of sensory and compound muscle action potentials. EDX studies of the upper extremities suggested a demyelinating polyneuropathy, most likely CMT disease. Genetic studies subsequently confirmed CMT type 1A (CMT1A) disease. Ensuing EDX studies on the patient's father and brother also suggested CMT1A disease. Physicians should be aware of the overlapping signs and symptoms of CMT disease and TCS. Performing comprehensive EDX studies prior to a TCR particularly in cases when a lumbar MRI is negative may prove valuable in identifying cases of CMT disease with subsequent confirmation by genetic testing.
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Shahrestani S, Brown NJ, Loya J, Patel NA, Gendreau JL, Himstead AS, Pierzchajlo N, Singh R, Sahyouni R, Diaz-Aguilar LD, Rennert RC, Levy ML. Novel use of nonpenetrating titanium clips for pediatric primary spinal dural closure: A technical note. Clin Neurol Neurosurg 2022; 222:107422. [PMID: 36084429 DOI: 10.1016/j.clineuro.2022.107422] [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: 05/02/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dural closure is an important part of any pediatric spinal procedure with intradural pathology to prevent post-operative cerebrospinal fluid (CSF) egress and associated complications. Utilization of nonpenetrating titanium clips is one closure option that may have technical advantages such as ease of use and amenability to a narrow surgical corridor. No data exist on the efficacy of these clips for pediatric spinal dural closure. METHODS A single surgeon case series of 152 pediatric patients underwent procedures involving lumbar durotomy with subsequent dural closure using the AnastoClip® nonpenetrating titanium clip closure system. Rates of infection and cerebrospinal fluid leak were measured during the follow-up period. RESULTS A total of 152 pediatric patients (mean age: 6.25 ± 5.85 years, 50.7 % female) underwent intradural surgery with clip closure. The mean follow-up time was 57.0 ± 28.5 months. All patients were initially indicated for procedures involving spinal durotomy, with a majority being isolated tethered cord release (84.2 %). Others required tethered cord release and excision of a lipomyelomeningocele, spinal meningioma or arachnoid cyst (15.8 %). Post operative CSF leak occurred in two (1.32 %) patients at 11 and 18 days. Only one (0.66 %) patient was diagnosed with an infection, which was in a separate patient from those that had CSF leaks. CONCLUSION The remarkably low incidence of post-operative CSF leak and infection with nonpenetrating titanium clips suggests a strong safety and efficacy profile for this form of dural closure in a pediatric cohort. Further research evaluating this technique is required to fully demonstrate its acceptability as a cost-effective alternative to traditional suture-based closure.
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Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Nolan J Brown
- School of Medicine, University of California, Irvine, Orange, CA, USA.
| | - Joshua Loya
- Department of Neurosurgery, University of California, La Jolla, San Diego, CA, USA
| | - Neal A Patel
- School of Medicine, Mercer University, Columbus, GA, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD, USA
| | | | | | - Rohin Singh
- School of Medicine, University of California, Irvine, Orange, CA, USA
| | - Ronald Sahyouni
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Luis Daniel Diaz-Aguilar
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California, La Jolla, San Diego, CA, USA; Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, USA
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22
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Yarandi KK, Pour-Rashidi A, Mortazavi A, Shirani M, Mohammadi E, Karimiyarandi H, Amirjamshidi A. Pitfalls in diagnosis of cord tethering in scoliosis: Lessons learned from a series in a single centre. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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23
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Cowley N, Maheshwari M, Lerner DG, Lew S, Lal D, Knezevich M, Lingongo M, Gourlay D. Assessment of MRI and US Screening for Tethered Cord Syndrome in Patients Diagnosed With Esophageal Atresia/Tracheoesophageal Fistula. J Surg Res 2022; 279:193-199. [PMID: 35779449 DOI: 10.1016/j.jss.2022.06.004] [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: 12/31/2021] [Revised: 05/05/2022] [Accepted: 06/08/2022] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Infants with esophageal atresia and/or tracheoesophageal fistula (EA/TEF) undergo screening for tethered cord syndrome (TCS) via ultrasound and magnetic resonance imaging. Existing literature lacks data to guide optimal timing of screening and magnetic resonance imaging (MRI) is often delayed until 3-6 mo of age, when it is frequently forgotten. Detethering surgery has a high rate of success in patients with TCS and is often performed prophylactically due to potential irreversible deficits. This study aims to improve screening procedure for infants with EA/TEF. METHODS A retrospective chart review was done of all EA/TEF patients treated over 6 y (n = 79). The study examined how often each imaging modality was performed and identified a TCS lesion, as well as age of screening/surgical intervention. RESULTS Screening for TCS was done with MRI 58% of the time and US 15% of the time. However, 38% of patients did not undergo any screening. Out of the patients with TCS on MRI (n = 19, 41.3%), 73.7% had neurosurgery. Of patients who underwent US (n = 12), nine patients also had MRI later: two reported TCS lesions and subsequently had neurosurgery. Surgical infection rates and complications were 0/14. CONCLUSIONS MRI demonstrated a higher rate of detecting TCS lesions than US, and patients with TCS frequently had detethering. Patients with ≥3 VACTERL or vertebral anomalies had a higher incidence of TCS on MRI. Patients with vertebral anomalies reported false negative ultrasounds in two cases, suggesting the potential superiority of MRI screening in this subgroup. A third of children did not undergo any imaging and this will require a process improvement.
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Affiliation(s)
- Norah Cowley
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Mohit Maheshwari
- Division of Pediatric Neuroradiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Diana G Lerner
- Department of Pediatric Gastroenterology, Medical College of Wisconsin, Clinics Building, Milwaukee, Wisconsin
| | - Sean Lew
- Division of Pediatric Neurosurgery, Medical College of Wisconsin, Hub for Collaborative Medicine, Milwaukee, Wisconsin
| | - Dave Lal
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michelle Knezevich
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Melissa Lingongo
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Gourlay
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Edström E, Wesslén C, Fletcher-Sandersjöö A, Elmi-Terander A, Sandvik U. Filum terminale transection in pediatric tethered cord syndrome: a single center, population-based, cohort study of 95 cases. Acta Neurochir (Wien) 2022; 164:1473-1480. [PMID: 35482074 PMCID: PMC9160100 DOI: 10.1007/s00701-022-05218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/19/2022] [Indexed: 12/02/2022]
Abstract
Purpose The purpose of this study was to evaluate outcome following surgical transection of filum terminale (FT) in symptomatic and asymptomatic pediatric patients with radiological findings consistent with tethered cord syndrome (TCS). Methods Patients < 17 years who underwent untethering surgery between 2007 and 2018 were screened for eligibility. Those who had undergone primary transection of the FT, and had preoperative radiological findings of fatty filum, thickened FT, or low-lying conus, below the pedicles of L2, were included. The cohort was divided into symptomatic and asymptomatic depending on clinical presentation. Surgical complications and functional outcome was recorded. Results In total, 95 patients were included, of whom 62 were symptomatic. In symptomatic patients, the main indications for radiological evaluation were scoliosis (29%) and motor symptoms (19%). In asymptomatic patients, skin stigmata (76%) were the most common finding. Fatty or thick FT was the most common radiographic finding, seen in 61% of symptomatic and 79% of asymptomatic cases. All patients underwent transection of the FT and were followed for a median of 1.8 years. A postoperative complication occurred in 12%, all Ibanez type Ib and managed without invasive treatment. For the symptomatic cohort, significant improvement was seen for both urodynamic assessment (48% improved, p = 0.002) and sensorimotor function (42% improved, p < 0.001). Conclusions Neurological improvement or halted deterioration was seen in the majority of symptomatic cases. Asymptomatic patients did not experience any severe complications. Filum transection should be offered to symptomatic and asymptomatic patients upon diagnosis of fatty filum, thickened FT, or low-lying conus.
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25
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Jiang Q, Tao B, Gao G, Sun M, Wang H, Li J, Wang Z, Shang A. Filum Terminale: A Comprehensive Review with Anatomical, Pathological, and Surgical Considerations. World Neurosurg 2022; 164:167-176. [PMID: 35500871 DOI: 10.1016/j.wneu.2022.04.098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/28/2022]
Abstract
The conus medullaris is the distal tapering end of the spinal cord, and the filum terminale (FT) is regarded as a bundle of non-functional fibrous tissue; therefore, some scholars call it the spinal ligament, while others describe the human FT as "remnants of the spinal cord." It was later found that in the human spinal cord, the FT is composed of an intradural segment and an epidural segment, and the end of the FT is connected to the coccyx periosteum. Because some nerve tissue is also found in the FT, as research progresses, FT may have the potential for transplantation. A lack of exhaustive overviews on the FT in the present literature prompted us to conduct this review. Considering that a current comprehensive review seemed to be the need of the hour, herein, we attempted to summarize previous research and theories on the FT, elucidate its anatomy, and understand its pathological involvement in various diseases.
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Affiliation(s)
- Qingyu Jiang
- Chinese PLA Medical School, Beijing 100853, China
| | - Benzhang Tao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, China; Tianjin Medical University
| | - Gan Gao
- Chinese PLA Medical School, Beijing 100853, China
| | - Mengchun Sun
- Chinese PLA Medical School, Beijing 100853, China; Medical School, Nankai University, Nankai District, Tianjin, China
| | - Hui Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, China
| | - Junyang Li
- Chinese PLA Medical School, Beijing 100853, China; Medical School, Nankai University, Nankai District, Tianjin, China
| | | | - Aijia Shang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing 100853, China.
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Klinge PM, Srivastava V, McElroy A, Leary OP, Ahmed Z, Donahue JE, Brinker T, De Vloo P, Gokaslan ZL. Diseased filum terminale as a cause of tethered cord syndrome in Ehlers Danlos syndrome: histopathology, biomechanics, clinical presentation, and outcome of filum excision. World Neurosurg 2022; 162:e492-e502. [DOI: 10.1016/j.wneu.2022.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
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Vertebral Column Shortening for Recurrent Tethered Cord Syndrome. World Neurosurg 2021; 157:240-241. [PMID: 34929768 DOI: 10.1016/j.wneu.2021.09.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Housley SB, Patel D, Nyabuto E, Reynolds RM. Spinal cord detethering without laminectomy or laminotomy. Surg Neurol Int 2021; 12:610. [PMID: 34992926 PMCID: PMC8720436 DOI: 10.25259/sni_942_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/09/2021] [Indexed: 11/04/2022] Open
Abstract
Background:
Tethered cord syndrome occurs when there is abnormal tension on the distal spinal cord, which limits its elevation as patients grow. This results in stretching of the neural elements and microvasculature, resulting in both direct and ischemic injury.[7] Animal studies suggest that impairment of oxidative metabolic pathways may contribute to neuronal injury.[7] Associated conditions include myelomeningocele, lipomyelomeningocele, intraspinal lipomas, diastematomyelia, thickened/fatty filum terminale, and trauma.[2] Tethering may be asymptomatic or result in a variety of symptoms including lower extremity weakness/sensory deficits, bowel/bladder dysfunction, scoliosis, pes cavus, and back/leg pain.[6] Early surgical intervention has been shown to improve outcomes and may be performed prophylactically or to prevent symptom progression.[1,3] More specifically, retrospective studies demonstrate that surgical intervention in patients under the age of 2 years is associated with improved outcomes.[5] In some cases, detethering may result in clinical improvement.[3]
Case Description:
We present a case of a 6-month-old male with a low-lying conus medullaris, lumbar syrinx, mildly abnormal urodynamic studies, and asymmetric utilization of his lower extremities observed during the evaluation of a Y-shaped gluteal cleft. He underwent elective spinal cord detethering via the safe and effective, minimally invasive technique described in the video.
The patient’s parents gave informed consent for treatment and video recording. Institutional review board approval was deemed unnecessary.
Conclusion:
Given the variety of surgical techniques used for cord detethering, this video may assist other surgeons in developing techniques that require little to no compromise of the developing bony spinal column while achieving sufficient release of the spinal cord.[4]
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Affiliation(s)
- Steven B. Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
| | - Devan Patel
- College of Medicine, Florida State University, Tallahassee, Florida, United States
| | - Elizabeth Nyabuto
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
| | - Renée M. Reynolds
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
- Department of Neurosurgery, John R. Oishei Children’s Hospital, Buffalo, New York, United States
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Zhao Z, Shabani S, Agarwal N, Mummaneni PV, Chou D. Intradural view of the spinal cord and dura after three-column osteotomy: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21497. [PMID: 36061976 PMCID: PMC9435575 DOI: 10.3171/case21497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND A three-column osteotomy results in dural buckling, which may appear concerning upon intraoperative visualization because it may appear that the neural elements may also be buckled. The authors presented an intraoperative view after intentional durotomy of the neural elements and the relaxed state of the dura after three-column osteotomy. OBSERVATIONS A 52-year-old woman with adult tethered cord syndrome and previous untethering presented with worsening leg pain and stiffness, urinary incontinence, and unbalanced gait. Magnetic resonance imaging demonstrated an arachnoid web at T6 and spinal cord tethering. Spinal column shortening via three-column osteotomy was performed with concomitant intradural excision of the arachnoid web. Dural buckling was observed intraoperatively after spinal column shortening. After the durotomy, the spinal cord was visualized without kinking or buckling. LESSONS Dural buckling after spinal column shortening of 15 mm via three-column osteotomy at T6 did not result in concomitant buckling of the underlying neural elements.
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Affiliation(s)
- Zirun Zhao
- Renaissance School of Medicine, Stony Brook University, Stony Brook, New York; and
| | - Saman Shabani
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Abstract
Context: Tethered cord syndrome is a progressive condition usually diagnosed early in life, and leads to a diversity of manifestations including neurologic, urologic, and orthopedic dysfunction.Findings: We report two cases of tethered cord syndrome associated with a unilaterally absent sural sensory response on nerve conduction studies while other causes of this finding being excluded.Conclusion/clinical relevance: We believe that this finding is caused by a selective injury of sensory fibers at the level or distal to the dorsal root ganglia.
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Affiliation(s)
- Elia G. Malek
- Neurology department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Johnny Salameh
- Neurology department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Estaitieh
- Neurology department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Achraf Makki
- Neurology department, American University of Beirut Medical Center, Beirut, Lebanon,Correspondence to: Achraf Makki, Neurology Department, American University of Beirut Medical Center, P.O. Box 11-0236, Riad El-Solh, 1107 2020Beirut, Lebanon; 961-1-350000/374374.
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Rezaee H, Keykhosravi E. Effect of untethering on occult tethered cord syndrome: a systematic review. Br J Neurosurg 2021; 36:574-582. [PMID: 34709093 DOI: 10.1080/02688697.2021.1995589] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite the evident clinical, neurological, orthopedic, and urodynamic dysfunctions, neuroanatomic imaging is normal in patients with occult tethered cord syndrome (OTCS). Therefore, the diagnosis of OTCS can be very complex. In this regard, this systematic review aimed to determine the main clinical features (i.e. neurological, musculoskeletal, and urological abnormalities) and improvement rates of these symptoms in patients with OTCS after the section of the filum terminale (SFT). MATERIALS AND METHODS All the papers published in three electronic databases, namely Google Scholar, PubMed, and Web of Science, were searched for the purposes of this study. The searching process started on 15 October and lasted until 9 November 2020. Eventually, 10 reports were found about the clinical outcomes of SFT for the management of the OTCS. RESULTS The included studies were carried out on a total of 234 patients with OTCS, all of whom had undergone SFT. Evaluation of urologic symptoms revealed that 40-100% of patients with OTCS suffered from urinary instability. Moreover, its improvement rate after SFT was estimated at 59-100%. Evaluation of neurological symptoms indicated that 25-69% of patients with OTCS suffered from back/leg pain, And its improvement rate, the symptoms of back/leg pain of all patients were resolved or improved after SFT. Lower extremity weakness was found in 9-40% of patients with OTCS which was resolved or improved after SFT in about 25-100% of patients. Nevertheless, surgical indications for occult tight filum terminale syndrome remain controversial. CONCLUSION Although it seems that the SFT in OTCS patients is promising in treating neurologic, orthopedic and urological symptoms, usage of surgical untethering for patients with OTCS is a controversial issue. Clinical evaluation and urodynamic testing can be used to identify patients with OTCS. However, a multidisciplinary diagnostic work-up is strongly recommended for every child with OTCS.
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Affiliation(s)
- Hamid Rezaee
- Neurosurgery Department, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ehsan Keykhosravi
- Neurosurgery Department, Mashhad University of Medical Sciences, Mashhad, Iran
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Takagi Y, Yamada H, Ebara H, Hayashi H, Kidani S, Toyooka K, Ishino Y, Kitano Y, Nakanami A, Kagechika K, Yahata T, Tsuchiya H. Intrathecal baclofen therapy for severe spasticity in an adult with tethered cord syndrome: a case report. J Med Case Rep 2021; 15:442. [PMID: 34470662 PMCID: PMC8411508 DOI: 10.1186/s13256-021-03049-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/05/2021] [Indexed: 11/16/2022] Open
Abstract
Background Patients with tethered cord syndrome often suffer severe spasticity. To the best of our knowledge, intrathecal baclofen (ITB) therapy in a patient with tethered cord syndrome has not been reported previously. We describe a case in which ITB therapy was useful for treating severe spasticity in an adult with tethered cord syndrome. Case presentation We present the case of a 50-year-old Japanese woman with tethered cord syndrome and related conditions suffering from severe spasticity and pain in the lower limbs. She was born with a lumbosacral myelomeningocele, which was closed in the neonatal period. For 4–5 years before this presentation, spasticity in the lower limbs had been exacerbated without any obvious cause. She received rehabilitation and pharmacotherapy from a local doctor, but symptoms were unimproved, and her previous doctor referred her to this department. A test with 50 μg of intrathecally delivered baclofen showed total relief of spasticity and pain, so a pump was implanted for continuous baclofen delivery. During 24 months of follow-up, spasticity has remained under excellent control with baclofen at 38.5–41.0 μg/day. Conclusions ITB therapy proved extremely effective in this adult with severe spasticity from tethered code syndrome.
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Affiliation(s)
- Yasutaka Takagi
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan.
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Hidehumi Ebara
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Hiroyuki Hayashi
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Satoshi Kidani
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Kazu Toyooka
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Yuji Ishino
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Yoshiyuki Kitano
- Department of Orthopaedic Surgery, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Aki Nakanami
- Department of Rehabilitation Medicine, Tonami General Hospital, 1-61 Shintomi-cho, Toyama, 939-1395, Japan
| | - Kenji Kagechika
- Department of Rehabilitation Medicine, Toyama Prefectural Rehabilitation Hospital and Support Center for Children with Disabilities, 36 Shimoiino-machi, Toyama, 939-1395, Japan
| | - Tetsutaro Yahata
- Department of Rehabilitation Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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Giorgi PD, Schirò GR, Capitani P, D'Aliberti GA, Talamonti G. Surgical pathway proposal for severe paralytic scoliosis in adolescents with myelomeningocele. Childs Nerv Syst 2021; 37:2279-2287. [PMID: 33585957 DOI: 10.1007/s00381-021-05079-x] [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: 11/19/2020] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The increased life expectancy of patients with myelomeningocele led to the necessity of new management for addressing complex spine deformities with severe pelvic obliquity. Tethered cord release (TCR) and spinal fusion were described as treatment options. However, nowadays, the surgical strategy is not well defined and high rates of mechanical failures and complications are reported. Our aim was to propose a new two-stage surgical pathway to treat a selected group of severe myelomeningocele scoliosis. METHODS This is a retrospective series of myelomeningocele scoliosis in paralytic adolescent patients treated with concurrent TCR and posterior spinal fusion (PSF), followed by delayed anterior fusion (ASF) through minimally invasive lateral approach. Inclusion criteria were as follows: evolutive scoliosis in tethered cord syndrome and paraplegia, main curve >70°, pelvic obliquity >20°, and age between 10 and 18 years. Clinical, surgical, and radiographic parameters were evaluated preoperatively and at a mean follow-up (FU) of 2.8 years. RESULTS Six patients out of 58 met the inclusion criteria and were included in the study (mean age 12.3 years old). The mean curve and pelvic obliquity correction were 68.8% and 82%, respectively. No loss of correction was recorded at FU. One case of cerebrospinal fluid leakage requiring revision surgery was recorded. CONCLUSION To the best of our knowledge, this is the first study proposing a two-stage surgical pathway for severe MMC spinopelvic deformity treatment. Concurrent TCR and PSF with delayed minimally invasive ASF permitted to minimize complications providing good fusion rates without loss of correction and implant failure.
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Affiliation(s)
- Pietro Domenico Giorgi
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, Milan, Italy
| | - Giuseppe Rosario Schirò
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, Milan, Italy.
| | - Paolo Capitani
- Orthopedics and Traumatology Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, Milan, Italy
| | - Giuseppe Antonio D'Aliberti
- Neurosurgery Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Talamonti
- Neurosurgery Unit, Emergency and Urgency Department, A.S.S.T. Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Theodore N, Cottrill E, Kalb S, Zygourakis C, Jiang B, Pennington Z, Lubelski D, Westbroek EM, Ahmed AK, Ehresman J, Sciubba DM, Witham TF, Turner JD, Groves M, Kakarla UK. Posterior Vertebral Column Subtraction Osteotomy for Recurrent Tethered Cord Syndrome: A Multicenter, Retrospective Analysis. Neurosurgery 2021; 88:637-647. [PMID: 33372221 PMCID: PMC7884146 DOI: 10.1093/neuros/nyaa491] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Few have explored the safety and efficacy of posterior vertebral column subtraction osteotomy (PVCSO) to treat tethered cord syndrome (TCS). OBJECTIVE To evaluate surgical outcomes after PVCSO in adults with TCS caused by lipomyelomeningocele, who had undergone a previous detethering procedure(s) that ultimately failed. METHODS This is a multicenter, retrospective analysis of a prospectively collected cohort. Patients were prospectively enrolled and treated with PVCSO at 2 institutions between January 1, 2011 and December 31, 2018. Inclusion criteria were age ≥18 yr, TCS caused by lipomyelomeningocele, previous detethering surgery, and recurrent symptom progression of less than 2-yr duration. All patients undergoing surgery with a 1-yr minimum follow-up were evaluated. RESULTS A total of 20 patients (mean age: 36 yr; sex: 15F/5M) met inclusion criteria and were evaluated. At follow-up (mean: 23.3 ± 7.4 mo), symptomatic improvement/resolution was seen in 93% of patients with leg pain, 84% in back pain, 80% in sensory abnormalities, 80% in motor deficits, 55% in bowel incontinence, and 50% in urinary incontinence. Oswestry Disability Index improved from a preoperative mean of 57.7 to 36.6 at last follow-up (P < .01). Mean spinal column height reduction was 23.4 ± 2.7 mm. Four complications occurred: intraoperative durotomy (no reoperation), wound infection, instrumentation failure requiring revision, and new sensory abnormality. CONCLUSION This is the largest study to date assessing the safety and efficacy of PVCSO in adults with TCS caused by lipomyelomeningocele and prior failed detethering. We found PVCSO to be an excellent extradural approach that may afford definitive treatment in this particularly challenging population.
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Affiliation(s)
- Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan Cottrill
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Corinna Zygourakis
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bowen Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zach Pennington
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erick M Westbroek
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - A Karim Ahmed
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mari Groves
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Musick S, Ferguson J, Muizelaar JP. Successful Treatment of Chronic Back and Leg Pain With Lower Than Usual Placement of High-Frequency Spinal Cord Stimulation in a Patient With Uncorrected Tethered Cord: Case Report. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
BACKGROUND AND IMPORTANCE
Tethered cord syndrome (TCS) often leads to severe back and leg pain. The typical treatment to stall disease progression is untethering surgery, but this is not always effective for pain. Spinal cord stimulation (SCS) is an efficacious treatment for neuropathic pain. However, it has seldom been utilized in TCS cases. Moreover, with cord elongation, ideal paddle placement is not certain.
CLINICAL PRESENTATION
We present the case of a 77-yr-old male with severe chronic lower-back and lower-extremity pain. Magnetic resonance imaging (MRI) showed severe lumbar spine degenerative changes, along with a previously undiagnosed spina bifida and conus medullaris termination at L5. We felt that SCS would be the best treatment avenue for his chief complaint of pain. Due to cord elongation, we trialed lower placement of the high-frequency (HF)-SCS system at T11-T12, which led to 80% improvement in pain symptoms within 1 wk and ability to walk for the first time in a year. At his first follow-up appointment, the patient endorsed 80% to 90% relief of his lower-back and bilateral lower-extremity pain, which improved to 100% relief at 12 mo at last visit.
CONCLUSION
Only 4 other reports were identified in the literature utilizing SCS in TCS cases. Our case adds to the limited body of literature that SCS is an effective therapy for pain in TCS and degenerative spine disease. Only 2 other reports employed lower than usual lead placement. Our case demonstrates that lead placement may need to be changed to accommodate the elongated cord.
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Affiliation(s)
- Shane Musick
- Department of Neurosurgery, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia , USA
| | - Jessalyn Ferguson
- Department of Neurosurgery, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia , USA
| | - Jan Paul Muizelaar
- Department of Neurosurgery, Marshall University Joan C. Edwards School of Medicine, Huntington, West Virginia , USA
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Fernandez-Portilla E, Moreno-Acosta L, Dominguez-Muñoz A, Gonzalez-Carranza V, Chico-Ponce de Leon F, Davila-Perez R. Functional outcome after cord detethering in fecally incontinent patients with anorectal malformations. Pediatr Surg Int 2021; 37:419-424. [PMID: 33427923 DOI: 10.1007/s00383-020-04834-6] [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] [Accepted: 12/11/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Tethered cord (TC) occurs in 36% of patients with anorectal malformations (ARMs), for whom the benefit of detethering surgery remains unclear regarding bowel and/or bladder function. This study aimed to examine whether cord detethering could improve fecal and urinary incontinence in these patients. METHODS This was a retrospective study of TC patients (>3 years old) with fecal incontinence and ARMs, who underwent detethering surgery between 2016 and 2020 and were followed up for at least 6 months. RESULTS Of the 27 included patients, 55% had sacral ratios between 0.4 and 0.7, and in 37% it was < 0.4; the remaining 8% was over 0.7; 52% suffered from colonic hypermotility. After detethering surgery, partial fecal continence was achieved in five patients (18%); total fecal continence, in ten patients (37%); 12 (44%) remained fecally incontinent. Partial urinary continence was obtained in four cases (14%), and the number of patients with total urinary continence rose from 7 (25%) to 15 (55%). Lower extremity symptoms were also improved in 72% of the cases. Patients with colonic hypomotility were found to have a better functional outcome than those with colonic hypermotility (69% vs. 43%, respectively). CONCLUSION Our study demonstrated that detethering surgery led to remarkably improved bowel and bladder control in ARM patients with fecal incontinence, which, surprisingly, was not associated with sacral ratio.
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Affiliation(s)
- Emilio Fernandez-Portilla
- Colorectal Clinic, Hospital Infantil de Mexico Federico Gomez, Calle Doctor Márquez 162, Col Doctores, Del Cuauhtémoc, 06720, Mexico City, Mexico.
| | - Leticia Moreno-Acosta
- Colorectal Clinic, Hospital Infantil de Mexico Federico Gomez, Calle Doctor Márquez 162, Col Doctores, Del Cuauhtémoc, 06720, Mexico City, Mexico
| | - Alfredo Dominguez-Muñoz
- Colorectal Clinic, Hospital Infantil de Mexico Federico Gomez, Calle Doctor Márquez 162, Col Doctores, Del Cuauhtémoc, 06720, Mexico City, Mexico
| | | | | | - Roberto Davila-Perez
- Colorectal Clinic, Hospital Infantil de Mexico Federico Gomez, Calle Doctor Márquez 162, Col Doctores, Del Cuauhtémoc, 06720, Mexico City, Mexico
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Sparks CR, Woelfel C, Robertson I, Olby NJ. Association between filum terminale internum length and pain in Cavalier King Charles spaniels with and without syringomyelia. J Vet Intern Med 2021; 35:363-371. [PMID: 33426675 PMCID: PMC7848331 DOI: 10.1111/jvim.16023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 11/30/2022] Open
Abstract
Background Lumbar syringomyelia (SM), lumbosacral pain, and more caudal spinal cord termination are reported in Cavalier King Charles spaniels (CKCS). Data are lacking on the clinical relevance of alterations in their spinal cord terminal structures. Objectives To compare spinal cord termination level and filum terminale internum length (FTIL) with presence of lumbar SM and clinical signs in CKCS. Animals Forty‐eight CKCS. Methods In this prospective study, pain was quantified using owner and clinician assessments. Vertebral level of spinal cord and dural sac termination, presence of SM, and FTIL were determined from sagittal magnetic resonance imaging (MRI) sequences. Kappa and intraclass correlation (ICC) analyses determined interobserver reliability. The MRI findings were compared to owner and clinician‐reported pain quantification. Results Interobserver reliability was good for spinal cord and dural sac termination (kappa = 0.61 and 0.64, respectively) and excellent for FTIL (ICC: 92% agreement). The spinal cord terminated at 6th lumbar vertebra in 1, 7th lumbar vertebra in 31, and the sacrum in 15 dogs, and termination level was associated with lumbar SM (P = .002) but not clinical signs. Mean FTIL was 2.9 ± 1.08 mm; it was associated with owner‐reported pain (P = .033) and spinal palpation scores (P = .023). Painful CKCS without SM had shorter FTIL compared to normal CKCS and painful CKCS with SM (P = .02). Conclusions Painful CKCS without SM have decreased distance between the termination of the spinal cord and dural sac, suggesting a shorter FTIL. More caudal spinal cord termination is associated with development of lumbar SM.
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Affiliation(s)
- Courtney R Sparks
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Christian Woelfel
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Ian Robertson
- Department of Molecular Biomedical Sciences, North Carolina State University, Raleigh, North Carolina, USA
| | - Natasha J Olby
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA.,Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina, USA
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Brown OH, Makar KG, Ulma RM, Buchman SR, Kasten SJ, Muraszko KM, Vercler CJ. A Simplified Approach to Myelomeningocele Defect Repair. Ann Plast Surg 2021; 86:58-61. [PMID: 32349084 DOI: 10.1097/sap.0000000000002374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Repair of the soft tissue defect in myelomeningoceles remains challenging. The literature currently lacks a systematic approach, reporting high rates of complications. We present outcomes from the largest series to date and describe a simplified approach that minimizes morbidity and streamlines decision making. METHODS Patients 1 year or younger who underwent myelomeningocele repair between 2008 and 2018 were reviewed. Flap types were categorized by tissue composition. Complications were dichotomized into early and late (<30 days and >30 days postoperative, respectively). Logistic regression was used to measure the impact of flap tissue composition and skin closure technique on odds of postoperative complications. RESULTS Ninety-seven patients met inclusion criteria. Reoperation was required in only 3 (3.0%) patients-1 for wound dehiscence and 2 for surgical site infections. Zero cases of tethered cord or cerebrospinal fluid leak occurred. The most common minor complications were early wound complications (n = 18, 18.6%) and early infection (n = 5, 5.2%). Fascia-only flaps and muscle + other tissue flaps were not associated with higher odds of complications compared with muscle-only flaps (odds ratio [OR], 2.13; 95% confidence interval [CI], 0.53-8.50, P = 0.29; OR = 2.87, 95% CI 0.66-12.51, P = 0.16, respectively). Rhomboid flaps for skin closure were associated with higher odds of complications (OR, 4.47; 95% CI, 1.00-19.97; P = 0.05). CONCLUSIONS Our approach to myelomeningocele repair demonstrated no cases of secondary tethered cord or cerebrospinal fluid leak, and reoperative rates were extremely low. Because complications were unrelated to flap type, we recommend a simplified approach using any tissue type for dural coverage and 2-layer primary closure of the skin.
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Sankhe S, Dang G, Mathur S, Muzumdar D. Utility of CISS imaging in the management of tethered cord syndrome. Childs Nerv Syst 2021; 37:217-223. [PMID: 32803307 DOI: 10.1007/s00381-020-04789-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the utility of constructive interference in steady-state (CISS) sequence over T2-weighted (T2W) sequence in the accurate delineation of the tethering element on magnetic resonance (MR) imaging in patients of tethered cord syndrome (TCS) and correlation with intraoperative findings. METHODS MR findings of fifty-six consecutive patients with operative findings of TCS were studied. The intraoperative findings of all patients were studied and compared with the preoperative imaging findings on T2W imaging and CISS images. RESULTS CISS images provided more information than T2W imaging. The overall sensitivity of CISS in MR evaluation of patients with TCS was higher (99.17%) as compared with the T2W sequence (71.48%) especially in the detection of precise position/extent of tethered cord, assessment of filum terminale thickening, detection of a fibrous spur in cases of split cord malformation, detection of dorsal dermal sinus, and evaluation of its precise extent and ramifications. The area under the ROC curve was higher with CISS (0.99) than with T2W sequence (0.85) which reflects its good predictive value as a screening test. This information was useful to the operating surgeon. CONCLUSION CISS sequence for imaging TCS can help enhance the overall surgical outcome of the patients ensuring completeness of the surgery. CISS should be routinely performed in the work-up of patients with tethered cord syndrome.
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Affiliation(s)
- Shilpa Sankhe
- Department of Radiology, King Edward Memorial Hospital, Mumbai, India
| | - Garima Dang
- Department of Radiology, King Edward Memorial Hospital, Mumbai, India.
| | - Shobhit Mathur
- Department of Radiology, King Edward Memorial Hospital, Mumbai, India
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40
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Sun Y, Ning G, Li X, Qu H, Zeng J. MRI characteristics of the fetal tethered spinal cord: a comparative study. Int J Neurosci 2020; 132:975-984. [PMID: 33272085 DOI: 10.1080/00207454.2020.1858829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Purpose: To compare fetuses and children with confirmed tethered cord syndrome to age-matched controls to provide a reference for prenatally identifying tethered spinal cord and to identify salient points on MRI for diagnosis.Materials and Methods: This retrospective study enrolled 13 fetuses and 20 children with tethered cord syndrome, and age-matched counterparts were included as controls. The MRI features including concomitant malformations, position of the conus medullaris, and thickened filum terminale of the two patient groups were evaluated and compared. Levels of the conus medullaris were discriminated between patients and an equivalent number of controls.Results: Various concomitant malformations manifested on the MRI of all patients, and there were differences between the two patient groups. Significant differences of the level of the conus medullaris were found between the fetal and child patients (U, 26.50; Z, -3.87; p < 0.001) and between the normal fetus and child controls (U, 23.50; Z, -4.13; p < 0.001). The position of the conus medullaris was visibly lower in the patient groups than in the control groups. No significant difference in the diameters of the filum terminale was found between the fetal and child patients (p = 0.67).Conclusions: The current study's results indicate that tethered spinal cord syndrome can be diagnosed in utero with MRI combined with several characteristics, particularly the position of the conus medullaris. Special attention should be paid to the gestational age of the fetus because normal changes in spinal cord position occur with gestational development.
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Affiliation(s)
- Yan Sun
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Gang Ning
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Xuesheng Li
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Haibo Qu
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Jiangang Zeng
- Department of Radiology, West China Second Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
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Zarzycki A, Thomas ZM, Mazrier H. Comparison of inherited neural tube defects in companion animals and livestock. Birth Defects Res 2020; 113:319-348. [PMID: 33615733 DOI: 10.1002/bdr2.1848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022]
Abstract
Neural tube defects (NTDs) are congenital malformations resulting from the improper or incomplete closure of the neural tube during embryonic development. A number of similar malformations of the protective coverings surrounding the central nervous system are also often included under this umbrella term, which may not strictly fit this definition. A range of NTD phenotypes exist and have been reported in humans and a wide range of domestic and livestock species. In the veterinary literature, these include cases of anencephaly, encephalocele, dermoid sinus, spina bifida, and craniorachischisis. While environmental factors have a role, genetic predisposition may account for a significant part of the risk of NTDs in these animal cases. Studies of laboratory model species (fish, birds, amphibians, and rodents) have been instrumental in improving our understanding of the neurulation process. In mice, over 200 genes that may be involved in this process have been identified and variant phenotypes investigated. Like laboratory mouse models, domestic animals and livestock species display a wide range of NTD phenotypes. They remain, however, a largely underutilized population and could complement already established laboratory models. Here we review reports of NTDs in companion animals and livestock, and compare these to other animal species and human cases. We aim to highlight the potential of nonlaboratory animal models for mutation discovery as well as general insights into the mechanisms of neurulation and the development of NTDs.
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Affiliation(s)
- Alexandra Zarzycki
- Faculty of Science, School of Life and Environmental Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Zoe M Thomas
- Faculty of Science, Sydney School of Veterinary Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Hamutal Mazrier
- Faculty of Science, School of Life and Environmental Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Science, Sydney School of Veterinary Science, The University of Sydney, Sydney, New South Wales, Australia
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Lane VA, Calisto J, deBlaauw I, Calkins CM, Samuk I, Avansino JR. Assessing the previously repaired patient with an anorectal malformation who is not doing well. Semin Pediatr Surg 2020; 29:150995. [PMID: 33288142 DOI: 10.1016/j.sempedsurg.2020.150995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this review, the care of children with a previously repaired anorectal malformation is explored. We know that the surgical care of children with anorectal malformations is complex; however, despite an increased understanding of the congenital anomaly and significant technical advances in the operative repair, many of these children continue to have poor functional outcomes. In this article we focus on the common surgical complications, discuss typical presentations, consider appropriate investigations, and review the risks and benefits of revisional surgery in those patients that are 'not doing well' following their primary reconstruction.
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Affiliation(s)
- Victoria A Lane
- Department of Paediatric Surgery, Great North Children's Hospital, Newcastle-Upon-Tyne, UK.
| | - Juan Calisto
- Colorectal Center, Nicklaus Children's Hospital, Miami, FL, USA
| | - Ivo deBlaauw
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Casey M Calkins
- The Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Inbal Samuk
- Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Jeffrey R Avansino
- Reconstructive Pelvic Medicine Program, Seattle Children's Hospital, Seattle, WA, USA; Department of Surgery, University of Washington, USA
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Filum Terminale Lipoma with Herniated Intervertebral Disc Treated with Traditional Korean Medicine: A Case Report. JOURNAL OF ACUPUNCTURE RESEARCH 2020. [DOI: 10.13045/jar.2020.00143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Filum terminale lipoma is an inherited lumbosacral abnormality that can cause tethered cord syndrome. This report describes an unusual case of lumbago and sciatica, pain suspected to be caused by a filum terminale lipoma where a herniated intervertebral disc had occurred. The patient was hospitalized for 43 days and received integrative Korean medicine treatment, including acupuncture, pharmacopuncture, Chuna therapy, cupping therapy, physiotherapy and herbal medicine. Treatment effectiveness was assessed using the numerical rating scale, Oswestry Disability Index, European Quality of Life 5-Dimensions, and patient symptoms. After inpatient treatment, the pain the patient suffered was significantly reduced, and the evaluation indices scores reflected this. Integrative Korean remedies may be an effective option for lower back pain and lower extremity symptoms which are caused by filum terminale lipoma where a herniated intervertebral disc has occurred. Additional clinical research is required to support this observation.
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Behbahani M, Shlobin N, Rosen C, Yerkes E, Swaroop V, Lam S, Bowman R. Multidisciplinary Management of Tethered Spinal Cord Syndrome in Children: Operationalizing an Outpatient Patient-Centered Workflow. J Multidiscip Healthc 2020; 13:1283-1290. [PMID: 33149598 PMCID: PMC7604938 DOI: 10.2147/jmdh.s274296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction Multidisciplinary care for patients with tethered spinal cord syndrome (TCS) is valuable in ensuring comprehensive evaluation, timely follow-up, optimal functional outcome, and patient-centered care. The family-centered focus aims to minimize patient and parental burdens associated with care coordination. We present our first-year institutional experience in operationalizing a multidisciplinary, patient-centered, pediatric tethered cord clinic (TCC) to manage routine, long-term surgical follow-up for children with non-myelomeningocele-related tethered spinal cords. Methods TCC is composed of three surgical services: orthopedic surgery, neurosurgery, urology. A retrospective chart review of patients seen in the TCC from January 2019 to January 2020 was conducted. Patients enrolled in the clinic were intended for long-term follow-up. Demographic and outcome variables were collected. Results Fifty-nine patients were seen in TCC. Types of tethered spinal cords amongst these patients were the following: fatty filum (62.7%), dermal sinus tract (15.2%), meningocele manqué (8.4%), lipomyelomeningocele (6.7%), low lying conus medullaris (5.1%), and sacral arachnoid cyst (1.7%). Age at diagnosis was 1.31 ± 2.21 (median: 0.25 years) and at follow-up was 9.0 ± 5.18 years (median: 8 years). A total of 50.9% of patients were female, and 93.2% had a prior untethering procedure. Of all patients, 6.8% have no surgical intervention and continue to be monitored conservatively for evidence of decline. All three services evaluated 84.8% of patients during the same clinic session, while 15.3% of patients were seen by two of the services, and 20.3% of patients were able to schedule related imaging or diagnostic testing during the same visit. Conclusion We describe successful implementation of a multidisciplinary pediatric TCC and document the first year of experience. The TCC streamlines care, decreases burden on families, and reduces those lost to follow-up. Complex disease pathologies, even when clinically stable, require long-term follow-up with multiple subspecialties and benefit from multidisciplinary clinics.
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Affiliation(s)
- Mandana Behbahani
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nathan Shlobin
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Colleen Rosen
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elizabeth Yerkes
- Division of Pediatric Urology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Vineeta Swaroop
- Division of Pediatric Orthopedic Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Orthopedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandi Lam
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robin Bowman
- Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Gigliotti MJ, Tachie-Baffour Y, Jafrani RJ, Lane J, Rizk E. A Novel Case of Tethered Cord in a Five-Month-Old Male With Pallister-Killian Syndrome. Cureus 2020; 12:e11240. [PMID: 33269168 PMCID: PMC7704268 DOI: 10.7759/cureus.11240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2020] [Indexed: 02/03/2023] Open
Abstract
A five-month-old male presented with an incidentally found low-lying conus medullaris on ultrasound and subsequent MRI demonstrating its position at L4. Pre-operative examination findings included mild, global hypotonia and a coccygeal dimple without bladder or bowel abnormalities or spasticity. The patient underwent spinal cord untethering with a section of filum terminale and was discharged without complication following his procedure. Follow-up at one year revealed continued baseline hypotonia without further neurosurgical needs. This is the first reported case of tethered cord syndrome described in a patient with Pallister-Killian syndrome managed successfully with neurosurgical intervention.
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Affiliation(s)
- Michael J Gigliotti
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Yaw Tachie-Baffour
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Ryan J Jafrani
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Jessica Lane
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Anatomic factors predict urinary continence in patient with anorectal malformation. J Pediatr Urol 2020; 16:545.e1-545.e7. [PMID: 32798105 DOI: 10.1016/j.jpurol.2020.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 11/21/2022]
Abstract
It has been described that patients with more complex anorectal malformations (ARM), lower sacral ratios and spinal anomalies have poorer rates of fecal and urinary continence. While the ARM subtype has been shown to be an independent predictor of fecal continence, it is not well understood how each of these anatomic factors impact urinary continence. The purpose of this study was to identify anatomic factors associated with urinary continence in children born with ARM. We performed a retrospective review of a large prospectively collected database of children with ARM. Inclusion criteria included diagnosis of ARM, age >4 years, available lateral sacral ratio measurement and presence of spinal MRI. Any child with incomplete or absent continence data was excluded. Continence was defined as voiding per urethra volitionally, dry between voids and ≤1 urinary accident per week. Bivariable tests of association and log-binomial regression models were used to examine association between anatomic factors and urinary continence. A total of 434 patients were included in the study. 57.8% (n = 251) were male. Median age was 8.4 years (IQR 6.0-12.3). With regards to severity of ARM, 20.3% (n = 88) were complex, 23.3% (n = 101) were moderate and 56.5% (n = 245) were simple. Lateral sacral ratio included 11.1% (n = 48) that were <0.4, 36.2% (n = 157) 0.4-0.7 and 52.8% (n = 229) > 0.7. Spine status was found to be myelomeningocele in 4.4% (n = 19), low conus or tethered cord in 34.8% (n = 151) and normal or fatty filum in 60.8% (n = 264). Overall 62.2% were continent. ARM severity, lateral sacral ratio and spine status were each independent predictors of urinary continence on univariate and multivariable analysis. We conclude that in children born with ARM, the severity of ARM, lateral sacral ratio and spine status each independently predict urinary continence. These results allow us to better understand these complex patients and their ability to develop urinary continence. This is crucial in enabling proper patient and family counseling and thus, setting appropriate expectations.
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Borgstedt-Bakke JH, Wichmann TO, Gudmundsdottir G, Rasmussen MM. The incidence and effect of tethered cord release for tethered cord syndrome in patients with myelomeningocele: a population-based study. J Neurosurg Pediatr 2020; 26:269-274. [PMID: 32470933 DOI: 10.3171/2020.4.peds19722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to establish an incidence and assess the effect of tethered cord release for tethered cord syndrome in patients with myelomeningocele. METHODS The study population was based on the Western Denmark Myelomeningocele Database, which contains all patients born with myelomeningocele in western Denmark since 1970. The study population was cross-referenced in 2015 with a database for surgical procedures containing all surgical procedures performed in the central Denmark region since 1996. Patients alive between 1996 and 2015 were identified. Incidences was calculated and presented for year of age. File reviews were conducted for all patients who underwent the procedure. Follow-up was divided into short-term and long-term follow-up. RESULTS One hundred sixty-six patients were alive during various time periods between 1996 and 2015. Of these, 45 patients underwent the procedure. Seven underwent reoperation. The median age for the procedure was 12 years and the highest incidence was found at 15 years of age. Incidence was bimodal with highest incidence in children and adolescents. The most common indications were progressive spine deformity (40%), deteriorating ambulation (38%), and deteriorating neurogenic bladder and/or bowel dysfunction (32%). The mean short-term follow-up was 4.7 months and the mean long-term follow-up was 72.6 months. Postoperatively, the majority had improved (27%) or stabilized (27%) at short-term follow-up. At long-term follow-up, most patients were stable (27%) or had deteriorated (24%). For both follow-up terms there was a loss of approximately one-third of all patients. Complications occurred in 17% of the procedures. CONCLUSIONS In this population-based study, tethered cord release has the highest incidence in children and adolescents. The beneficial effect of the procedure seems to be short term. Due to the uncertainty of a long-term effect of the procedure in patients with myelomeningocele and the registered complications, the authors suggest that this surgical indication should be reserved for well-selected patients.
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Finger T, Aigner A, Depperich L, Schaumann A, Wolter S, Schulz M, Thomale UW. Secondary tethered cord syndrome in adult patients: retethering rates, long-term clinical outcome, and the effect of intraoperative neuromonitoring. Acta Neurochir (Wien) 2020; 162:2087-2096. [PMID: 32588295 DOI: 10.1007/s00701-020-04464-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The strategy for surgical treatment of tethered cord syndrome in pediatric patients is well established but still bares challenges for adult patients. This retrospective study was performed to assess the surgical outcome of adult patients with a secondary tethered cord syndrome and to evaluate the benefit of intraoperative neuromonitoring. METHODS Clinical charts of 32 consecutive adult patients who underwent in total 38 surgical untethering procedures at our facility between 2008 and 2018 were retrospectively analyzed. Epidemiological data, MRI scans, and postoperative results were evaluated. RESULTS The retethering rate in our patient cohort was 16%. Main complaints were maximal pain (82%), bladder dysfunction (79%), paresthesia (68%), and weakness in the lower extremities (68%). Forty-eight months after surgery, patients' symptoms generally improved, with an average level of pain of 19.1% (95% CI, 5.7-32.5%), paresthesia 28.7% (95% CI, 12.6-44.8%), weakness in the lower extremities 27.7% (95% CI, 11.1-44.4%), and bladder dysfunction 60.2% (95% CI, 41.6-78.7%). The use of neuromonitoring appears to have a positive impact on patient weakness (OR = 0.07; 95% CI, 0.01-0.68) and paresthesia (OR = 0.03; 95% CI, 0.00-2.18). This benefit is less clear for the retethering rate (OR = 0.45; 95% CI, 0.06-3.26) or the overall clinical outcome (OR = 0.70; 95% CI, 0.14-3.45). The presence of a preoperative Chiari syndrome, syringomyelia, or scoliosis had no relevant influence on the retethering rate. CONCLUSIONS Our data confirms that untethering surgery in adult patients is relatively safe and has a reasonable chance of clinical improvement of pain, paresthesia, and weakness in the lower extremities. The use of intraoperative monitoring has a positive influence on the improvement of preoperative paralysis.
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Affiliation(s)
- Tobias Finger
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Annette Aigner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lukas Depperich
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Schaumann
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Simone Wolter
- University Clinic of Anesthesiology and Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthias Schulz
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Day EL, Proctor MR, Scott RM. Surgical volume of simple tethered spinal cord releases: review of a large pediatric neurosurgical service experience. J Neurosurg Pediatr 2020; 26:60-64. [PMID: 32244206 DOI: 10.3171/2020.2.peds19743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to retrospectively review, from a single busy pediatric neurosurgical service, a consecutive series of patients who had undergone surgery for a simple tethered spinal cord, which was defined by a thickened or fatty filum terminale with a normal conus. The hope was to contribute to benchmark data regarding the expected frequency of surgery for this condition. METHODS The authors reviewed the electronic medical records of every patient with diagnosed simple tethered spinal cord, defined on spinal MRI as a thickened (> 2 mm in diameter) or fatty filum terminale, and who had undergone primary filum section at Boston Children's Hospital between 2005 and 2011. RESULTS A total of 208 patients met the study inclusion criteria. At the time of surgery, patients ranged in age from 0.4 to 19.8 years. One hundred forty-four (69%) patients were symptomatic with one or more of the following: bowel/bladder dysfunction, 94 (45%); neurological dysfunction, 49 (24%); scoliosis, 44 (21%); or back pain, 44 (21%). Sixty-four (31%) patients were asymptomatic and were operated on prophylactically when filum pathology was discovered during the course of a workup for clinical syndromes such as anorectal anomalies and/or suspicious cutaneous lesions. No patients in this series were operated on if they had normal MRI studies, defined as a conus tip no lower than L3 and no distal tethering lesion visualized. Over the study period, approximately 1000 major surgical cases were performed in the department every year, only 30 of which were simple detethering procedures, representing well under 5% of the service's operative volume and approximately 5 cases per surgeon per year. Clinical follow-up, available at a postoperative interval of 6.6 ± 3.8 years, demonstrated that approximately 80% of patients symptomatic with bowel or bladder involvement or neurological dysfunction had improvement or relief of their symptoms and that none of the patients treated prophylactically experienced new-onset symptoms that could be related to spinal tethering. CONCLUSIONS Simple detethering procedures were relatively uncommon in an active, well-established pediatric neurosurgical service and represented less than 5% of the service's total case volume per year with an average of 5 cases per surgeon per year. No patients with normal MRI studies were operated on during the study period.
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Finger T, Schaumann A, Grillet F, Schulz M, Thomale UW. Retethering after transection of a tight filum terminale, postoperative MRI may help to identify patients at risk. Childs Nerv Syst 2020; 36:1499-1506. [PMID: 31875245 DOI: 10.1007/s00381-019-04458-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/28/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Retethering after transection of a tight filum terminale (TFT) deemed to be a rare and usually only years after initial surgery occurring complication. Possible perioperative factors that might influence the retethering rate or help to allow a prognostic risk assessment are still poorly investigated. The aim of this study was to analyze our patient cohort who underwent a TFT transection by assessing clinical outcome, retethering rate, and pre- and postoperative MRI studies. METHODS All consecutive patients undergoing transection of a TFT from January 2011 to December 2018 were evaluated. Inclusion criteria were defined as exclusive TFT intervention and a minimum follow up period of 1 year. Epidemiological data, treatment modalities, complication characteristics, and MRI studies were recorded and analyzed. RESULTS A total of 58 patients met our inclusion criteria. The retethering rate in our patient cohort was 5.2% (3/58); one of the three patients developed two episodes of a retethering. Patients with an unchanged conus level, no improvement in the syringomyelia, and an unchanged thickness of the spinal cord postoperatively seem to have a significant higher risk to develop a retethering episode in the follow-up. CONCLUSION Retethering after transection of the filum terminale did occur more often than expected. Certain existing factors on the routine postoperative MR images may help to identify patients with an increased likelihood to develop a retethering episode. These results may contribute to improve the follow-up for patients after transection of a TFT and may facilitate adequate treatment.
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Affiliation(s)
- Tobias Finger
- Department of Pediatric Neurosurgery, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Schaumann
- Department of Pediatric Neurosurgery, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Francois Grillet
- Department of Pediatric Neurosurgery, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthias Schulz
- Department of Pediatric Neurosurgery, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Department of Pediatric Neurosurgery, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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