Reversal of longstanding neurological deficits after a late release of tethered spinal cord

Metabolomics of neurological disorders in India

Metabolomics is the comprehensive study of the metabolome and its alterations within biological fluids and tissues. Over the years, applications of metabolomics have been explored in several areas, including personalised medicine in diseases, metabolome-wide association studies (MWAS), pharmacometabolomics and in combination with other branches of omics such as proteomics, transcriptomics and genomics. Mass spectrometry (MS) and nuclear magnetic resonance (NMR) spectroscopy are the major analytical techniques widely employed in metabolomics. In addition, MS is coupled with chromatography techniques like gas chromatography (GC) and liquid chromatography (LC) to separate metabolites before analysis. These analytical techniques have made possible identification and quantification of large numbers of metabolites, encompassing characterization of diseases and facilitating a systematic and rational therapeutic strategy based on metabolic patterns. In recent years, the metabolomics approach has been used to obtain a deeper insight into the underlying biochemistry of neurodegenerative disorders and the discovery of biomarkers of clinical implications. The current review mainly focuses on an Indian perspective of metabolomics for the identification of metabolites and metabolic alterations serving as potential diagnostic biomarkers for neurological diseases including acute spinal cord injury, amyotrophic lateral sclerosis, tethered cord syndrome, spina bifida, stroke, Parkinson's disease, glioblastoma and neurological disorders with inborn errors of metabolism.

Evaluation and management of tethered cord syndrome in occult spinal dysraphism: Recommendations from the international children's continence society

AIMS

As awareness and frequency of tethered spinal cord (TSC) related to occult spinal dysraphism (OSD) has increased with magnetic resonance imaging (MRI), variability exists in its evaluation and management. Due to no published level I data, we summarize the current International Children's Continence Society (ICCS) recommendations for diagnosis and treatment of OSD.

METHODS

Guidelines were formulated based on analysis of pertinent literature and consensus among authors. This document was vetted by the multidisciplinary members of the ICCS via its website before submission for peer review publication.

RESULTS

The more frequent diagnosis of OSD is associated with increased operative intervention. Spinal cord untethering (SCU) has a highly variable risk profile, largely dependent on the specific form of OSD. Progressive neurological deterioration attributed to "tethered cord" may occur, with or without surgery, in selected forms of OSD whereas other cohorts do well.

CONCLUSION

Infants with classic cutaneous markers of OSD, with progressive neurologic, skeletal, and/or urologic findings, present no diagnostic or therapeutic dilemma: they routinely undergo MRI and SCU. Conversely, in asymptomatic patients or those with fixed, minor abnormalities, the risk profile of these OSD cohorts should be carefully considered before SCU is performed. Irrespective of whether or not SCU is performed, patients at risk for progression should be followed carefully throughout childhood and adolescence by a multidisciplinary team.

Early identification of tethered cord syndrome: a clinical challenge

Tethered cord syndrome (TCS) is a progressive clinical condition that arises from excessive spinal cord tension. The clinical signs and symptoms of TCS may be cutaneous, neurologic, musculoskeletal, genitourinary, and/or gastrointestinal. Patients also may be asymptomatic, which does not exclude the diagnosis of TCS. Although the exact etiology is unknown, early identification and lifelong surveillance or surgical treatment is an essential component of patient management. In this article we review the pathophysiology, various etiologies, clinical presentation, and long-term sequelae of TCS. This information will help pediatric nurse practitioners identify TCS early and anticipate the patient's needs and management requirements.

When only partial spinal cord detethering is possible

In most instances, initial surgery to untether a tethered spinal cord is successful. But what happens when it is not? The authors describe the case of a now 18-year-old woman with spina bifida in whom surgery for tethered cord was required on two occasions. In both instances, due to the extent of her underlying lesion and fibrous tissue, only partial detethering was possible without acutely sacrificing significant neurological function. The authors detail the patient's course and review the peer-reviewed scientific literature on outcomes in patients in whom only partial cord detethering is achieved. In their review of all case series and clinical studies pertaining to the surgical treatment of tethered cord syndrome identified during an online search of 2184 scientific abstracts and 2 major neurosurgery textbooks, excluding the present case, the authors identified 53 confirmed or presumed cases of incomplete detethering in eight articles, incorporating 390 patients, for an overall prevalence of roughly 13.6%. Although no investigators have reported statistical comparisons of outcomes in those in whom just partial and complete detethering has been achieved, the evidence generally suggests poorer outcomes in the former. Prospective multicenter studies addressing this important issue clearly are warranted. To date, the authors believe that incomplete detethering is grossly underreported in the medical literature.