Evaluation of tethered cord syndrome associated with anorectal malformations

Development of a Standardized Algorithm for Management of Newly Diagnosed Anorectal Malformations

Neonates with a new diagnosis of anorectal malformation (ARM) present a unique challenge to the clinical team. ARM is strongly associated with additional midline malformations, such as those observed in the VACTERL sequence, including vertebral, cardiac, and renal malformations. Timely assessment is necessary to identify anomalies requiring intervention and to prevent undue stress and delayed treatment. We utilized a multidisciplinary team to develop an algorithm guiding the midline workup of patients newly diagnosed with ARM. Patients were included if born in or transferred to our neonatal intensive care unit (NICU), or if seen in clinic within one month of life. Complete imaging was defined as an echocardiogram, renal ultrasound, and spinal magnetic resonance imaging or ultrasound within the first month of life. We compared three periods: prior to implementation (2010-2014), adoption period (2015), and delayed implementation (2022); p ≤ 0.05 was considered significant. Rates of complete imaging significantly improved from pre-implementation to delayed implementation (65.2% vs. 50.0% vs. 97.0%, p = 0.0003); the most growth was observed in spinal imaging (71.0% vs. 90.0% vs. 100.0%, p = 0.001). While there were no differences in the rates of identified anomalies, there were fewer missed diagnoses with the algorithm (10.0% vs. 47.6%, p = 0.05). We demonstrate that the implementation of a standardized algorithm can significantly increase appropriate screening for anomalies associated with a new diagnosis of ARM and can decrease delayed diagnosis. Further qualitative studies will help to refine and optimize the algorithm moving forward.

State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations

Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.

Anorectal malformations with good prognosis: variables affecting the functional outcome

BACKGROUND/PURPOSE

The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis.

METHODS

Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery.

RESULTS

6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p=0.0029 and p=0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5±7.2mmHg vs 32±7.9mmHg, p=0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22±10.24mmHg vs 32.57±6.68mmHg, p=0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p=0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p=0.014).

CONCLUSIONS

Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.

Clinical characteristics and surgical outcome in 25 cases of childhood tight filum syndrome

OBJECTIVE

Tight filum syndrome (TFS) is caused by a thick (abnormal T1 MRI), shortened (low-lying conus), or non-elastic filum (strictly normal MRI). We carefully analyzed children treated for suspect TFS with or without radiological abnormalities.

METHODS

Twenty-five children, operated between 2002 and 2009, were retrospectively identified. All children had been evaluated by a multidisciplinary team preoperatively. Symptoms, signs and diagnostic test results were categorized (neurologic, urologic, orthopedic, dermatologic) and compared pre- and one year postoperatively. Normal MR was defined as conus medullaris (CM) at or above mid-body L2 and filum diameter less than 2 mm. Occult TFS (OTFS) was defined as TFS with normal MR.

DEMOGRAPHICS

17 girls, 8 boys, age 2-18 years, including 11 syndromal children.

CLINICAL PRESENTATION

all children had problems in the neurologic category and at least one other category: urologic (n = 17), orthopedic (n = 21), and dermatologic (n = 11). MR findings: low-lying CM (n = 14) including 2 with thick filum, normal CM but fatty filum (n = 2), strictly normal (n = 9). Clinical outcome one year postoperatively: neurologic 20 improved, 5 stabilized; urologic 13 improved, 3 stabilized, 1 worsened; orthopedic (8 children presenting with scoliosis) 3 improved, 4 stabilized, 1 worsened. All children with OTFS (n = 9) improved in at least one and 8 improved in all affected categories.

CONCLUSIONS

Children with strong clinical suspicion for TFS (≥ 2 affected categories) with or without abnormal MR findings will likely benefit from surgery. In such cases we suggest a detailed full spine MR, a multidisciplinary diagnostic work-up, and eventual untethering through an interlaminar microsurgical approach.

Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence?

BACKGROUND/PURPOSE

Anorectal malformations (ARM) are a spectrum of defects ranging from the very minor ones, with an excellent functional prognosis, to those that are more complex, often associated with other anomalies, difficult to manage and with a poor functional outcome. A significant number of these children suffer from fecal and urinary incontinence despite major advances in the management of ARM patients have significantly improved the quality of life. The role of sacrovertebral anomalies/dysraphism (SD) and neurospinal cord anomalies/dysraphism (ND) associated with ARM on the continence of these patients is still controversial. The authors made a review of their experience in a period of 5 years, focusing on the role of neurospinal cord anomalies in patients with ARM.

MATERIALS

At colorectal clinic of our department of pediatric surgery 215 patients who underwent a procedure of posterior sagittal anorectoplasty for ARM are followed-up in a multidisciplinary clinic. Among them 60 patients with either SD or ND were documented. In 37 patients the anomaly involved the spinal cord (ND). 12 of these 37 patients underwent neurosurgical treatment and 25 were managed conservatively. Data collected from their follow-up were analyzed and compared, focusing on their bowel and urinary continence.

RESULTS

All 37 patients acquired regular bowel movements with an appropriate bowel management according to Peña's protocols. Urinary incontinence required clean intermittent catheterization in four cases. None of the patients who did not receive neurosurgical treatment developed acute complications due to the progression of the neurospinal anomaly, like acute urinary retention, orthopedic and motility problems or acute hydrocephalus. From literature review we were unable to find good evidence that the presence of ND worsens the functional prognosis of patients with ARM. We were also unable to find convincing evidence to support the practice of prophylactic neurosurgical procedures.

CONCLUSIONS

The present study supports the theory that for ARM patients the prognosis in terms of continence depends mainly on the type of malformation and is not complicated by the association with ND. In our series neurosurgical treatments did not have any effect in improving the continence of ARM patients and a conservative management of ND did not expose the patients to the sequelae of progressive deterioration, reported elsewhere, requiring rescue neurosurgery. We believe that the correct practice of pediatric surgeons following-up ARM patients is a protocol which includes appropriate investigations to detect the presence of a SD or ND and, once these entities are detected, it is mandatory to manage the patient with a multidisciplinary team, where a conservative non-operative management is initially justified and advocated in the absence of neurosensorymotor symptoms.

Defective development of sensory neurons innervating the levator ani muscle in fetal rats with anorectal malformation

BACKGROUND

Defects of the pelvic nerve innervation of levator ani muscle are associated with poor postoperative anorectal function in patients with anorectal malformation (ARM). We have previously shown deficient development of motoneurons innervating the levator ani muscle in rats with ARM. In this study we investigate whether there is a deficiency in the development of sensory neurons that innervate the levator ani muscle in rats with ARM.

METHODS

ARM was induced by ethylenethiourea (ETU) in fetal rats. Retrograde tracer fluorogold (FG) was injected into the levator ani muscle. Serial transverse sections encompassing the entire length of the lumbosacral spinal cord were examined. The number of FG-labeled sensory neurons was scored and compared between fetuses with ARM and normal fetuses.

RESULTS

The number of FG-labeled sensory neurons innervating the levator ani muscle in normal control fetuses, ETU-fed fetuses with no malformation, low type of imperforate anus, high type of imperforate anus, and high type of imperforate anus combined with neural tube defects were determined to be (mean +/- SEM) 11,804 +/- 2362, 10,429 +/- 1708, 2886 +/- 705, 1026 +/- 425, and 964 +/- 445, respectively. FG-labeled sensory neurons in fetuses with imperforate anus with or without neural tube defects were significantly fewer than in control and ETU-fed fetuses without malformation (p < 0.05).

CONCLUSIONS

Defective sensory neurons innervating the levator ani muscle is a primary anomaly that coexists with the alimentary tract anomaly in ARM during fetal development. Nerve innervation deficiency of the pelvic muscles contributes to the poor postoperative anorectal functions in ARM patients.

Tethered cord in patients with anorectal malformation: preliminary results

BACKGROUND

A tethered cord (TC) has been reported in as much as 50% of the patients affected by anorectal malformation (ARM). No guidelines for timing and modality of diagnosis and treatment have been established. We present the preliminary results of a multidisciplinary protocol carried out at our center.

METHODS

Seventy-four ARM patients underwent spinal magnetic resonance imaging (MRI). All TC patients underwent videourodynamic (UD), somatosensory-evoked potentials (SEPs), and neurological examination at baseline and, if normal, at 5 and 10 years of age. Conversely, when UD or SEP abnormalities were detected the follow-up was individually tailored at shorter time.

RESULTS

25/74 patients had a neuroradiological TC (33.7%). Based on the results of UD, SEP, and neurological status, four patients were untethered, eight are possible candidates, nine are stable, and four were excluded because of incomplete data.

DISCUSSION

Tethered cord is frequent in ARM patients. Because neurological deficits secondary to TC can contribute to neurological disability, we recommend routine MRI examination and a multidisciplinary program of follow-up in cases of TC. Preliminary results suggest the combined use of SEPs and UD could represent a useful adjunct to clinical examination in patients in whom a "wait and see" approach is preferred to the prophylactic surgery.

The value of ultrasonic examination of the lumbar spine in infants with specific reference to cutaneous markers of occult spinal dysraphism

AIM

To present part of the rationale behind the recent update to the M12 guideline in The Royal College of Radiologists' publication "Making the best use of a department of clinical radiology", 4th edition 1998, which stated that ultrasound was useful in screening for dysraphism in infants with cutaneous markers such as sacral dimple or hairy patch.

MATERIALS AND METHODS

Over a 10-year period a total of 223 infant lumbar spines were scanned, for various clinical indications. Forty of these patients had already had abnormalities detected antenatally by foetal ultrasonography. One hundred and eight-three patients had abnormalities detected on postnatal clinical examination; most of these had various cutaneous markers, some had other congenital abnormalities.

RESULTS

There were a total of 29 patients with dysraphism; 24 were detected antenatally and five postnatally. Of the five, two had two or more cutaneous markers and three had anorectal anomalies. All 86 of the patients with simple sacral dimples, pits or sinuses were normal.

CONCLUSION

As an isolated abnormality, simple dimples or pits are not useful markers of spinal dysraphism. The authors suggest a new imaging protocol, resulting in improved diagnostic efficiency.

Spinal lipoma associated with terminal syringohydromyelia and a spinal arachnoid cyst in a patient with cloacal exstrophy

CASE REPORT

A 2-year-old girl presented with repaired cloacal exstrophy and a subcutaneous mass at the midline of the lumbosacral region. Neurological examination revealed mild paraparesis with bilateral lower-extremity hyperreflexia and sensory disturbance below the level of L4. A CT scan showed asymmetrical spina bifida on the right side extending from L2 to L5, and symmetrical spina bifida below S1. Magnetic resonance imaging showed a low-set conus with terminal syringohydromyelia, lumbosacral lipoma, and the extradural arachnoid cysts at Th12-L4 compressing the spinal dural sac from behind. Surgical removal of the arachnoid cyst and lipoma relieved spinal dural sac compression and the tethered spinal cord. The patient showed an improvement in the lower-extremity hyperreflexia postoperatively.

CONCLUSION

The rare association of the cloacal exstrophy with the multiple spinal cord abnormalities as shown in the present case indicates that detailed routine screening of the spinal cord is necessary for the careful planning of treatment in patients with anorectal anomalies.

Urinary incontinence and vesicourethral dysfunction in pediatric surgical conditions

The most common cause for urinary incontinence in children with pediatric surgical conditions of the pelvic region and perineum is lower urinary tract dysfunction caused by concomitant sacral agenesis, especially in children with anorectal malformations. Another common cause is iatrogenic pelvic nerve damage secondary to reconstructive surgery. Moreover, an intrinsically altered pelvic floor anatomy as seen in some cases of complex cloacas, or disruption of pelvic floor muscles with consecutive loss of supportive structures, as in sacrococcygeal teratoma, should also be taken into consideration. It is important to understand that the causes of urinary incontinence in these children are not isolated problems concerning only the urinary tract. They may have the same negative impact on anorectal function as they have on the bladder and urethral sphincter. Therefore, children with pediatric surgical conditions of the pelvic and perineal region often will present with a combination of both fecal incontinence caused by anorectal dysfunction and urinary incontinence caused by vesicourethral dysfunction. The additional morbidity caused by urinary incontinence may have an enormous impact on the patient's life and well being, not only with regard to physical disability, but also in terms of emotional problems, social handicap, and socioeconomic burden. It is obvious that a patient's quality of life will be significantly reduced if he or she suffers from both fecal and urinary incontinence. Therefore, an integrated approach to the management of both vesicourethral and anorectal dysfunction should be developed to achieve the optimum care for these children.

The tethered spinal cord in patients with anorectal malformations

The aims of this study were to find the prevalence of tethered cord in patients with anorectal malformations; to determine if the presence of tethered cord relates to the severity of the anorectal defect, and to certain symptoms, signs, radiologic findings, and associated anomalies; and finally to determine whether tethered cord impacted on a patient's functional prognosis and whether surgical untethering improved the patient. The authors studied 934 patients with anorectal malformations, 111 of whom had magnetic resonance imaging (MRI) of the spine. We compared patients with and without tethered cord by using parametric and nonparametric statistical tests. Tethered cord occurred in 24% of the patients. The prevalence varied according to the type of anorectal defect from 43% in the complex group to 11% in patients with rectovestibular fistula. Patients with tethered cord had a lateral sacral ratio lower than that of patients without tethered cord (0.410 versus 0.702). Tethered cord was present in 90% of patients with myelodysplasia, 60% of patients with a presacral mass, 57% of patients with sacral hemivertebrae, and 56% of patients with a single kidney. The greater number of associated anomalies a patient had, the greater the risk of having tethered cord (P < .05 for all differences). The authors noted differences between patients with and without tethered cord in the presence of voluntary bowel movements (46% versus 70%), fecal soiling (91% versus 63%), constipation (21% versus 43%), and urinary incontinence (86% versus 42%). The data indicate that patients with tethered cord have a worse functional prognosis than patients without tethered cord. However, the incontinence in our patients was also predictable based on the type of anorectal defect and the character of the sacrum irrespective of the presence of tethered cord. Eighteen patients underwent surgical untethering of the cord, and none had any significant change in bowel or urinary function postoperatively. No patient with tethered cord experienced incontinence that could be attributed to the cord defect alone. This study suggests that tethered cord occurs more frequently in patients with severe anorectal defects, sacral hypodevelopment, myelodysplasia, presacral mass, sacral hemivertebrae, or a single kidney, or in those with an anorectal defect with poor functional prognosis. At present no solid evidence supports the concept that tethered cord by itself affects the functional prognosis of patients with anorectal malformations. Also, there is no good evidence demonstrating that surgical untethering improves the prognosis.

Occult spinal dysraphism in the infant

The progressive neurologic dysfunction caused by occult spinal dysraphism can be prevented with early clinical recognition, radiographic diagnosis, and neurosurgical treatment. However, detection of occult spinal dysraphism in the infant is difficult because neurologic symptoms often are not apparent until the child becomes ambulatory. Occult spinal dysraphism, however, can be suspected in the asymptomatic neonate when cutaneous stigmata, such as hemangiomas, hairy patches, deep and/or eccentric dimples, or subcutaneous masses are seen over the lumbosacral spine. Because of the serious, often irreversible, sequelae of a delayed diagnosis, spinal sonography of high-risk infants with midline, lumbosacral, cutaneous stigmata should be considered as an effective, noninvasive screening method.

Association of imperforate anus with occult spinal dysraphism

Neurological deficits may occur in some children with imperforate anus produced by unrecognized spinal cord anomalies amenable to neurosurgical correction. Although this association has been well described, its frequency has not been defined. The authors prospectively studied 45 infants with imperforate anus from 1985 to 1992 to establish the frequency of this association. Eighteen infants (40%) had high imperforate anus, 24 had low imperforate anus (53%), and 3 had anal stenosis (7%). All underwent radiographic spinal cord imaging in early infancy, which consisted of radiographs (45), ultrasound (26), magnetic resonance imaging (29), computed tomography (1), and myelography (1). Thirty-three percent of the patients with imperforate anus had bony sacral abnormalities. Eight infants were discovered to have spinal cord abnormalities. Two of those infants had obvious myelomeningocele at birth, and 6 infants (14%) had occult spinal dysraphism consisting of tethered cord with or without associated lipoma of the cord. There was no correlation between the presence of tethered cord and the gender of the infants, the type of malformation (high versus low imperforate anus), or the presence of sacral dysplasia (Fisher's exact test). Five of the infants who were found to have tethered cord underwent neurosurgical intervention and repair of the defect, and 1 infant was followed up clinically. The mean follow-up time of all the infants was 2.5 +/- 0.9 (+/- SD) years. No neurological sequelae occurred in the infants who had surgical correction. The frequency of occult spinal dysraphism with imperforate anus was 14%. It was independent of the type of imperforate anus or the coexistence of bony sacral anomalies.(ABSTRACT TRUNCATED AT 250 WORDS)