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Lin H, Su H, Li C, Zhang P, Xiu B, Bai Y, Xu R. Classification of and individual treatment strategies for complex tethered cord syndrome. Front Surg 2024; 11:1277322. [PMID: 38322409 PMCID: PMC10844385 DOI: 10.3389/fsurg.2024.1277322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/09/2024] [Indexed: 02/08/2024] Open
Abstract
Objective To study the classification, diagnosis, and treatment strategies of complex tethered cord syndrome (C-TCS) on the basis of the patients' clinical symptoms, imaging findings, and therapeutic schedule. Methods The clinical data of 126 patients with C-TCS admitted to our department from January 2015 to December 2020 were retrospectively analyzed. Classification criteria for C-TCS were established by analyzing the causes of C-TCS. Different surgical strategies were adopted for different types of C-TCS. The Kirollos grading, visual analogue scale (VAS), critical muscle strength, and Japanese Orthopaedic Association (JOA) scores were used to evaluate the surgical outcomes and explore individualized diagnosis and treatment strategies for C-TCS. Results C-TCS was usually attributable to three or more types of tether-causing factors. The disease mechanisms could be categorized as pathological thickening and lipomatosis of the filum terminal (filum terminal type), arachnoid adhesion (arachnoid type), spina bifida with lipomyelomeningocele/meningocele (cele type), spinal lipoma (lipoma type), spinal deformity (bone type), and diastomyelia malformation (diastomyelia type). Patients with different subtypes showed complex and varied symptoms and required individualized treatment strategies. Conclusion Since C-TCS is attributable to different tether-related factors, C-TCS classification can guide individualized surgical treatment strategies to ensure complete release of the tethered cord and reduce surgical complications.
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Affiliation(s)
- Hepu Lin
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Hui Su
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Cuicui Li
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Pengfei Zhang
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Bo Xiu
- Department of Neurosurgery, The First Medical Center of the PLA General Hospital, Beijing, China
| | - Yunjing Bai
- Department of Neurosurgery, The Seventh Medical Center of the PLA General Hospital, Beijing, China
| | - Ruxiang Xu
- Department of Neurosurgery, Sichuan Provincial People’s Hospital, Chengdu, China
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林 国, 谢 京, 陈 晓, 杨 军. [Classification and microsurgical treatment of primary tethered cord syndrome in adults]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:641-645. [PMID: 37534645 PMCID: PMC10398760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To summarize the clinical manifestation, classification, and experience of surgical treatment of primary tethered cord syndrome (TCS) in adults. METHODS The authors retrospectively analyzed a series of 171 adult patients with primary TCS who were surgically treated under microscope from March 2007 to October 2019. There were 61 males and 110 females whose ages were 18-65 years, with an average age of (39.02±11.81) years. Clinically, the patients presented with various neurological symptoms and signs including lower back and legs pain, reflex changes, sensory disturbances, muscle weakness, and sphincter problems. They were divided into 5 types by clinical manifestations and neuro-imaging features: (1) filum terminale traction in 69 cases, (2) split cord malformation in 21 cases, (3) myelomeningocele in 20 cases, (4) lipomyelomeningocele in 36 cases, and (5) dermal sinus traction in 25 cases. All the patients underwent microsurgery to untether the spinal cord. The patients kept prone position 7 days postoperatively. The Kirollos grading was used to evaluate the outcome of intraoperative untethering. The visual analogue scale (VAS) was used to evaluate the pain, the score of critical muscle strength was used to evaluate the lower extremity motor function, and the Japanese Orthopaedic Association (JOA) sphincter function score was used to evaluate the bladder function. RESULTS All of the 171 patients were treated with microsurgery to release the adhesion and cut off the filum terminalis. 61 cases of them received resection of the lesions according to the etiology. All the tethered spinal cord reached Kirollos grade Ⅰ untethering and the dural sac was reconstructed. Other than 5 patients had cerebrospinal fluid leakage and incision laceration and underwent re-suture, there was no surgical complication. The local pain was relieved, the lower limbs weakness or bowel and bladder dysfunction gradually recovered postoperatively. The period of follow-up ranged from 6 months to 12.5 years with an average of (5.62±2.31) years. The neurological function was improved in 153 cases and stable in 18 cases. There was no recurrence of tethered cord be found during the follow-up period. CONCLUSION The primary TCS in adulthood could be classified into 5 types by clinical manifestations and neuro-imaging features and surgical treatment should be undertaken in regard to the classifications including dissection and resection of the lesion detethering the spinal cord and reconstruction of the dura sac under microscope. The outcome of surgical treatment is satisfactory.
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Affiliation(s)
- 国中 林
- />北京大学第三医院神经外科, 北京大学医学部精准神经外科与肿瘤研究中心, 北京 100191Department of Neurosurgery, Peking University Third Hospital; Precision Neurosurgery and Tumor Research Center, Peking University Health Science Center, Beijing 100191, China
| | - 京城 谢
- />北京大学第三医院神经外科, 北京大学医学部精准神经外科与肿瘤研究中心, 北京 100191Department of Neurosurgery, Peking University Third Hospital; Precision Neurosurgery and Tumor Research Center, Peking University Health Science Center, Beijing 100191, China
| | - 晓东 陈
- />北京大学第三医院神经外科, 北京大学医学部精准神经外科与肿瘤研究中心, 北京 100191Department of Neurosurgery, Peking University Third Hospital; Precision Neurosurgery and Tumor Research Center, Peking University Health Science Center, Beijing 100191, China
| | - 军 杨
- />北京大学第三医院神经外科, 北京大学医学部精准神经外科与肿瘤研究中心, 北京 100191Department of Neurosurgery, Peking University Third Hospital; Precision Neurosurgery and Tumor Research Center, Peking University Health Science Center, Beijing 100191, China
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Wang YT, Mu GZ, Sun HL. Thoracolumbar surgery for degenerative spine diseases complicated with tethered cord syndrome: A case report. World J Clin Cases 2022; 10:10375-10383. [PMID: 36246831 PMCID: PMC9561563 DOI: 10.12998/wjcc.v10.i28.10375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/21/2022] [Accepted: 08/24/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tethered cord syndrome (TCS) secondary to split cord malformation (SCM) is rare in adulthood. There is as yet no consensus about the optimal treatment method for adult patients with SCMs and degenerative spine diseases such as lumbar stenosis, spondylolisthesis and ossification of the ligamentum flavum (OLF). The tethered cord poses a great challenge to the decompression and fusion procedures for the intraoperative stretching of the spinal cord, which might lead to deteriorated neural deficits. Here, we report on a case to add our treatment experience to the medical literature.
CASE SUMMARY We treated a 67-year-old female patient with type II SCM suffering from lumbar disc herniation, degenerative lumbar spondylolisthesis and thoracic OLF. The patient underwent thoracolumbar spinal fusion and decompression surgery for severe lower back pain, extensive left lower limb muscle weakness and intermittent claudication. After the thoracolumbar surgery, without stretching the tethered cord, the patient achieved complete relief of pain and lower extremity weakness at final follow-up.
CONCLUSION For adult patients with underlying TCS secondary to SCM coupled with thoracic OLF and lumbar spondylolisthesis, a thoracolumbar fusion surgery could be safe and effective with the tethered cord untreated. It is critical to design individualized surgical protocols to reduce the stretch of the low-lying spinal cord.
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Affiliation(s)
- Yue-Tian Wang
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
| | - Guan-Zhang Mu
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
| | - Hao-Lin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
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Kobets AJ, Oliver J, Cohen A, Jallo GI, Groves ML. Split cord malformation and tethered cord syndrome: case series with long-term follow-up and literature review. Childs Nerv Syst 2021; 37:1301-1306. [PMID: 33242106 DOI: 10.1007/s00381-020-04978-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/17/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE To date, the description of the natural course of concurrent tethered cord syndrome with a low-lying conus medullaris and split cord malformation is lacking in the literature. We report a cohort of adult and pediatric patients with concurrent malformations and long-term follow-up. METHODS Patients with concurrent diagnoses of split cord malformation and tethered cord (radiographic evidence supporting clinical symptomatology) were identified between 2000 and 2020. Patients without sufficient documentation or at least 6-month follow-up were excluded. RESULTS Nine patients were identified with an average of 8.9 years follow-up (range 2-31 years). The most common symptoms were radiating leg pain and lower extremity paresthesias, occurring in 44% of patients; and bladder/bowel dysfunction, worsening scoliosis, and acute motor deterioration were less common. Two patients were successfully treated conservatively for mild leg pain and paresthesias. For those who underwent surgery, all experienced symptomatic relief upon first follow-up. Two had late symptomatic recurrence; one 4 and 8 years after initial surgery; and the other, 11, 26, and 31 years after initial surgery. CONCLUSION The rarity of concurrent split cord and tethered cord syndrome with a low-lying conus makes management difficult to formulate. This series supplements our knowledge of the long-term outcomes and lessons learned from the management of these patients. Approximately 25% of patients were managed conservatively and had symptomatic improvement. For surgically managed patients, with intractable pain or worsening neurological function, symptoms can still recur over a decade after intervention. Reoperation, however, can still be beneficial, can provide years of relief, and should be considered.
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Affiliation(s)
- Andrew J Kobets
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Phipps Building, 5th Floor, Baltimore, MD, USA.
| | - Jeffrey Oliver
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Phipps Building, 5th Floor, Baltimore, MD, USA
| | - Alan Cohen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Phipps Building, 5th Floor, Baltimore, MD, USA
| | - George I Jallo
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Phipps Building, 5th Floor, Baltimore, MD, USA.,Department of Neurosurgery, Division of Pediatric Neurosurgery, All Children's Hospital, St. Petersburg, FL, USA
| | - Mari L Groves
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Phipps Building, 5th Floor, Baltimore, MD, USA
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Menezes AH, Seaman SC, Iii MAH, Hitchon PW, Takacs EB. Tethered spinal cord syndrome in adults in the MRI era: recognition, pathology, and long-term objective outcomes. J Neurosurg Spine 2021:1-13. [PMID: 33740756 DOI: 10.3171/2020.9.spine201453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tethered cord syndrome (TCS) has been well described in pediatric patients. Many recent reports of TCS in adult patients have grouped retethering patients with newly diagnosed ones without separately analyzing each entity and outcome. The authors reviewed their experience of newly diagnosed adult TCS patients to identify and explore TCS misdiagnosis, recognition, subtype pathology, and individual objective outcomes. METHODS This study included 24 adult patients (20 female and 4 male) who fit the criteria of being newly diagnosed and aged 20 years and older (age range 20-77 years). Preexisting dermal sinus was present in 6 patients, hypertrichosis in 5, skin tag/cleft/dimple and fatty subcutaneous masses in 5, scoliosis in 2, and neurological abnormalities in 4 patients. The pathology consisted of TCS with taut filum in 8 patients, conus lipoma with TCS in 7, diastematomyelia in 7, and cervical cord tethering in 2 patients. Of the 24 study patients, nondermatomal low-back or perineal pain occurred in 19 patients, bladder dysfunction in 21, and motor, sensory, and reflex abnormalities in 21 patients. Aggravating factors were repeated stretching, multiple pregnancies, heavy lifting, and repeated bending. Urological evaluation included bladder capacity, emptying, postvoid residuals, detrusor function, pelvic floor electromyography (EMG), bladder sensitivity, and sphincter EMG, which were repeated at 6 months and 1 year postoperatively. The follow-up was 1 to 30 years. Detailed postoperative neurological findings and separate patient outcome evaluations were recorded. Four of the 24 patients did not have an operation. RESULTS Resolution of pain occurred in 16 of the 19 patients reporting low-back or perineal pain. Motor and sensory complaints resolved in 17 of 20 patients. Regarding bladder dysfunction, in the 20 patients with available data, bladder function returned to normal in 12 patients, improved in 3 patients, and was unchanged in 5 patients. If the symptom duration was less than 6-8 months, there was recovery of all parameters of pain, bladder dysfunction, and neurological deficit, and recovery from hyperreflexia matched that from neurological deficit. Fifteen patients were employed preoperatively and returned to work, and an additional 3 others who were unable to work preoperatively were able to do so postoperatively. CONCLUSIONS Most adults with newly diagnosed TCS have unrecognized neurocutaneous abnormalities and neurological deficits. The triad of nondermatomal sacral or perineal pain, bladder dysfunction, and neurological deficit should not be confused with hip or degenerative lumbosacral disease. Addressing the primary pathology often leads to successful results.
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Incidentally discovered type 1 split cord malformation in an adult patient. Radiol Case Rep 2020; 15:1756-1758. [PMID: 32774575 PMCID: PMC7399242 DOI: 10.1016/j.radcr.2020.07.021] [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: 06/27/2020] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 11/20/2022] Open
Abstract
Split spinal cord syndrome (SCM), an entity of spinal dysraphisms, occurs rarely in adults and is associated with tethered cord syndrome, which commonly presents with back pain. Besides clinical findings, neuroimaging by Magnetic resonance imaging or computed tomography is needed for diagnosis. We report a case of a previously healthy 51-year-old man who presented for right upper abdominal quadrant pain. A computed tomography scan of the abdomen and pelvis incidentally discovered the diagnosis of type 1 SCM. This case highlights that SCM can remain asymptomatic throughout life to be diagnosed at one point by neuroimaging. Whenever no clinical complications exist, no surgical intervention might be indicated.
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Xu F, Wang X, Li L, Guan J, Jian F. Tethered Cord Syndrome Caused by Duplicated Filum Terminale in an Adult with Split Cord Malformation. World Neurosurg 2020; 143:7-10. [PMID: 32711136 DOI: 10.1016/j.wneu.2020.07.100] [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: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tethered cord syndrome (TCS) is a clinical diagnosis of progressive neurologic aggravation of the lower spinal cord due to a traction on the conus medullaris. Untethering surgery is effective for most TCS; however, when anatomic variations of spinal cord and filum terminale (FT) exist, regular untethering may lead to a failed outcome. CASE DESCRIPTION The authors present the case of a 45-year-old patient with TCS caused by duplicated FT with split cord malformation (SCM). Lumbosacral magnetic resonance imaging revealed a type II SCM with a significant low-lying conus medullaris. Laminectomy was performed. Neurophysiologic monitoring was used for nerve root identification and 2 thickened fila, which failed to respond on stimulation, were found during the surgery. Both fila were sectioned, and the diagnosis was finally confirmed by pathologic examination. Postoperatively, the patient's symptoms disappeared immediately and no neurologic sequela was found after surgery. CONCLUSIONS This is the first documented adult of duplicated FT with preoperative radiologic evidence and reported in association with SCM as a cause of TCS. When SCM exists, a careful observation for duplicated FT is warranted on preoperative magnetic resonance imaging and during surgery. Complete transection of the double FT under intraoperative neurophysiologic monitoring is the best treatment for this anomaly.
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Affiliation(s)
- Feifan Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China; Department of Neurosurgery, Peking University First Hospital, Beijing, P.R. China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China
| | - Liang Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, P.R. China
| | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China.
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