Tethered cord syndrome in adults

A 31-year follow-up of those with occult spinal dysraphism, who underwent spinal cord untethering: Lower urinary tract function, skin stigmata, fertility, and work participation

OBJECTIVES

This study evaluated patients with occult spinal dysraphism who underwent spinal cord untethering.

METHODS

Twenty-four patients who visited us between 1983 and 2000 were followed-up for a mean duration of 31 years. We studied their lower urinary tract function, skin stigmata, fertility, and work participation.

RESULTS

Questionnaires sent in 2022 revealed that 5 patients had normal voiding (Group A) and 19 patients had abnormal voiding (Group B). Groups A and B underwent spinal cord untethering at a mean age of 5.7 and 13.0 years, respectively, showing a significant statistical difference (p = 0.036). After spinal cord untethering, the number of patients with detrusor normoactivity increased from 0 to 5, i.e., 3 of 6 with detrusor overactivity (50%), 1 of 2 not examined, and 1 of 5 not known. Patients with detrusor underactivity also increased from 11 to 19. Severity of incontinence in the International Consultation on Incontinence Questionnaire-Short Form resulted in a mean value of 2.4 in Group A, which was significantly superior to the mean value of 9.1 in Group B (p = 0.004). Fourteen patients (58.3%) were married and had 21 healthy children. A majority of patients have had full-time jobs. A variety of skin stigmata were present in the lumbosacral region, and changes in vesico-urethral configurations were observed during a video-urodynamic study.

CONCLUSIONS

Our study identified that the early timing of spinal cord untethering performed in neonates or infants and detrusor overactivity prior to untethering surgery are important factors in achieving normal bladder function.

Intraoperative Neurophysiological Monitoring in Tethered Cord Syndrome Surgery: Predictive Values and Clinical Outcome

INTRODUCTION

"Tethered cord syndrome" (TCS) refers to a congenital abnormality associated with neurological signs and symptoms. The aim of surgery is to prevent or arrest their progression. This study reports a retrospective case series of tethered cord syndrome surgeries, supported by intraoperative neurophysiological monitoring.

METHODS

The case series comprises 50 surgeries for tethered cord syndrome in which multimodal intraoperative neurophysiological monitoring was performed using motor evoked potentials (transcranial motor evoked potentials [TcMEPs]), tibial nerve somatosensory evoked potentials (TNSEPs), and pudendal-anal reflex (PAR). The intraoperative neurophysiological monitoring results are reported and correlated with clinical outcomes.

RESULTS

Sensitivity, specificity, and negative predictive value were high for TcMEPs and TNSEPs, while PAR exhibited low sensitivity and positive predictive value but high specificity and negative predictive value. Fisher's exact test revealed a significant correlation between changes in TcMEPs, TNSEPs, and clinical outcome ( P < 0.000 and P = 0.049 respectively), but no correlation was detected between PAR and urinary/anal function ( P = 0.497).

CONCLUSIONS

While TcMEPs and TNSEPs were found to be reliable intraoperative neurophysiological monitoring parameters during tethered cord syndrome surgery, PAR had low sensitivity and positive predictive value probably because the reflex is not directly related to bladder function and because its multisynaptic pathway may be sensitive to anesthetics. New onset muscle weakness and sensory deficits were related to postoperative changes in TcMEPs and TNSEPs, whereas changes in PAR did not predict bladder/urinary impairment. Urinary deficits may be predicted and prevented with other neurophysiological techniques, such as the bladder-anal reflex.

Prognostication of the neurological outcome of tethered cord based on intraoperative neuromonitoring findings: how close can we get?

PURPOSE

To evaluate the correlation of intraoperative neuromonitoring (IONM) data in surgery for tethered cord syndrome (TCS) in children to the neurological outcome at 1-year follow-up.

METHODS

208 consecutive patients operated on for TCS, between January 2011 to February 2020, under electrophysiological monitoring in the Division of Paediatric Neurosurgery, AIMS, Kochi, India, were included. Their preoperative neurological, urological and orthopaedic status were compared with the postoperative status at 1 year follow-up.

RESULTS

Our study prospectively collected the IONM data and retrospectively correlated it to the children's neurological outcome on follow-up. Out of 208 children, 28% (n = 59/208) had motor, 35% (n = 73/208) had bladder and 26% (n = 54/208) had bowel disturbances. Postsurgery, at one-year follow-up, 91% (n = 52/57) of the patients who had motor deficits had improvement, 82.3% (n = 51/62) of patients who had bladder deficits showed an improvement, and 88.8% (n = 48/54) with bowel deficits showed improvement. The monitorability for motor and sphincter potentials were 99.4% and 89.3%, respectively. Except for four patients (3 with bladder and 1 with motor worsening), all the patients who were monitorable with no deficits remained intact except for four patients, all the patients who had deficits and were monitorable improved after detethering (at 1 year). Clinical worsening corresponded to those who had a drop in amplitude of baseline TcMEP (n = 4). 18 events showed an increase in amplitude compared to the baseline TcMEP. These patients improved clinically on follow-up (at 1 year).

CONCLUSIONS

IONM complements the preoperative clinical details in predicting immediate and long-term outcomes.

Aberrant Dorsal Nerve Root as a Concomitant Cause of Spinal Cord Tethering Associated with a Dorsal Type Lipomyelomeningocele in a Child With Caudal Agenesis

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.

Adult-onset Sacral Meningocele Causing a Specific Headache Triggered by Compression or Adoption of a Sitting or Supine Posture

We report a rare case of adult-onset sacral meningocele where compression triggered a specific headache. A 46-year-old woman presented with a headache, which worsened when she was in a sitting or supine position. A subcutaneous mass was observed on her left buttock, the compression of which also induced headache. No neurological deficits were evident. Lumbar and sacral magnetic resonance imaging demonstrated a meningocele in the left dorsal buttock, connecting to the sacral cerebrospinal fluid (CSF) space, and spinal computed tomography revealed sacral dysplasia. Initial meningocele resection improved the patient's headache, but the cyst recurred 2 years later. Following repeated surgery to reinforce the meningocele orifice, the headache was relieved and has been absent for more than 6 years. The headache was due to intracranial pressure fluctuations due to CSF influx into and drainage from the meningocele. Meningocele development in adulthood can be owing to a spinal bone defect and pressure load on the spinal dura. Surgical resection can improve symptoms resulting from meningocele, and reinforcement of the orifice using an artificial surgical membrane effectively prevents recurrence.

Diagnosis and Management of Tethered Cord Syndrome

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.

New Spinal Shortening Technique for Tethered Cord Syndrome: A Technical Note

Background and Objectives: To present a new spinal shortening technique for tethered cord syndrome. Tethered cord syndrome (TCS) is a debilitating condition leading to progressive neurological decline. Surgical detethering for TCS is the gold standard of treatment. However, symptomatic retethering of TCS has been reported in 5%-50% of patients after initial release. To solve this problem, posterior spinal shortening osteotomy has been reported. This technique has risks of massive blood loss and neurological deterioration. The authors hereby report a new safe spinal shortening technique for tethered cord syndrome. Materials and Methods: A 31-year-old man with gait disturbance was referred to our hospital. After the delivery of treatment, he underwent surgical untethering of the spinal cord in another hospital. He had hyperreflexia of the Achilles tendon reflex and bilateral muscle weakness of the legs (MMT 3-4). He also had urinary and bowel incontinence, and total sensory loss below L5. An anteroposterior lumbar radiogram indicated partial laminectomy of L3 and L4. Lumbar MRI showed retethering of spinal cord. Results: The patient underwent a new spinal shortening technique for tethered cord syndrome under the guidance of O-arm navigation. First, from the anterior approach, disectomy from T12 to L3 was performed. Second, from the posterior approach, Ponte osteotomy was performed from T12 to L3, shortening the spinal column by 15 mm. The patient was successfully treated surgically. Postoperative lumbar MRI showed that the tension of the spinal cord was released. Manual muscle testing results and the sensory function of the left leg had recovered almost fully upon final follow-up at one year. Conclusions: A retethered spinal cord after initial untethering is difficult to treat. This new spinal shortening technique can represent another good option to release the tension of the spinal cord.

Electrodiagnostic findings of retethering in children with spinal dysraphism

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.

Transition from partial to near-total/radical resection of spinal cord lipomas

PURPOSE

The objective of this retrospective study was to compare the outcomes and associated complication rates in the surgical management of spinal cord lipomas following a change of practice within our institution from partial resection (PR) to near-total/radical resection (NTR).

METHODS

Twenty-four children underwent surgical treatment for symptomatic spinal cord lipomas between 2009 and 2020. The near-total/radical resection group included 20 patients with spinal cord lipomas and the comparison group included 6 patients with spinal cord lipomas who underwent partial resection. Filar lipomas were excluded.

RESULTS

The mean age of the patients was 7 years (range 1-14 years). Post-operatively, a higher proportion of NTR patients (17/20, 85%) demonstrated improvement or stabilisation in Necker-Enfants Malades scores compared to PR patients (3/6, 50%) with a mean follow-up of 48 and 108 months respectively. Two patients underwent re-do untethering surgery, both of which initially underwent partial resection surgery. Complication rates did not significantly differ between the two groups.

CONCLUSION

Our data supports the view that near-total/radical resection should be considered the technique of choice over the conventional method of partial resection for spinal cord lipomas with no significant increase in complication rates.

Coexisting filum terminale arteriovenous fistula and filum terminale lipoma treated with single-stage surgery: illustrative case

BACKGROUND

Both filum terminale arteriovenous fistulas (FTAVFs) and filum terminale lipomas (FTLs) are rare. Because of this rarity, there is a paucity of data regarding concomitant FTAVF and FTL, and the optimal treatment remains to be defined. The authors describe a patient with coexisting FTAVF and FTL treated with single-stage surgery.

OBSERVATIONS

A man in his 70s was referred to the authors' department because of a suspected spinal vascular malformation seen on magnetic resonance imaging that was performed to investigate lower limb weakness, intermittent claudication, and urinary incontinence. Previous imaging had shown a terminal lipoma with an internal flow void. Computed tomography angiography and digital subtraction angiography revealed an FTAVF, the feeder being a lateral sacral artery. The patient was treated surgically with curative intent. The FTL and tethered cord that had been identified by imaging were treated in the same procedure. Postoperative digital subtraction angiography showed absence of the abnormal vessels. The patient was discharged home on the 19th postoperative day.

LESSONS

When considering treatment, it is important to determine whether symptoms are attributable mainly to FTL, tethered cord, or FTAVF. One-stage treatment is useful because it eliminates both the FTAVF and the factors that led to its development.

The Current Status of the Surgical Management of Complex Spinal Cord Lipomas: Still Navigating the Labyrinth?

This review summarises the classification, anatomy and embryogenesis of complex spinal cord lipomas and describes in some detail the technique of total lipoma resection and radical reconstruction of the affected neural placode. Its specific mission is to tackle two main issues surrounding the management of complex dysraphic lipomas: whether total resection confers better long-term benefits than partial resection and whether total resection does better than conservative treatment, i.e. no surgery, for asymptomatic lipomas. Accordingly, the 24-year progression-free survival data of the senior author and colleagues' series of over 300 cases of total resection are compared with historical data from multiple series (including our own) of partial resection, and total resection data specifically for asymptomatic lesions are compared with the two known series of non-surgical treatment of equivalent patients. These comparisons so far amply support the author's recommendation of total resection for most complex lipomas, with or without symptoms. The notable exception is the asymptomatic chaotic lipoma, whose peculiar anatomical relationship with the neural tissue defies even our aggressive surgical approach, and consequently projects worse results (admittedly of small number of cases) than for the other two lipoma subtypes of dorsal and transitional lesions. Prophylactic resection of asymptomatic chaotic lipomas is therefore not currently endorsed. We have also recently found that some dorsal lipomas with clear outline of the conus on preoperative imaging had a significantly better long-term prognosis of preserving neurourological functions without surgery. Whether this subset of lipomas should be managed conservatively until symptoms arise is now an open question awaiting a longer follow-up of a larger cohort of such patients.

A Novel Untethering and Duraplasty Technique for Postsurgical Tethered Spinal Cord

Progressive post-traumatic postsurgical myelopathy (PPPM) is a known entity that can occur months to years after the initial insult. Symptomatic patients can become myelopathic and have rapid and progressive neurological decline. Surgical correction of PPPM usually involves intradural exploration and lysis of adhesions that carries the risk of further injury to the spinal cord. In this manuscript, we provide a report of a patient presenting more than 50 years after the initial resection of an intramedullary tumor. Additionally, we present and describe a novel surgical technique for managing this difficult problem and restoring normal CSF dynamics.

Chiari Malformation Type 1 in Adults

The term Chiari malformation refers to a heterogeneous group of anatomical abnormalities at the craniovertebral junction. Chiari malformation type 1 (CM1) refers to the abnormal protrusion of cerebellar tonsils through the foramen magnum and is by far the commonest type. Its prevalence is estimated approximately 1%; it is more common in women and is associated with syringomyelia in 25-70% of cases. The prevalent pathophysiological theory proposes a morphological mismatch between a small posterior cranial fossa and a normally developed hindbrain that results in ectopia of the tonsils.In most people, CM1 is asymptomatic and diagnosed incidentally. In symptomatic cases, headache is the cardinal symptom. The typical headache is induced by Valsalva-like maneuvers. Many of the other symptoms are nonspecific, and in the absence of syringomyelia, the natural history is benign. Syringomyelia manifests with spinal cord dysfunction of varying severity. The approach to patients with CM1 should be multidisciplinary, and the first step in the management is phenotyping the symptoms, because they may be due to other pathologies, like a primary headache syndrome. Magnetic resonance imaging, which shows cerebellar tonsillar decent 5 mm or more below the foramen magnum, is the gold standard investigative modality. The diagnostic workup may include dynamic imaging of the craniocervical junction and intracranial pressure monitoring.The management of CM1 is variable and sometimes controversial. Surgery is usually reserved for patients with disabling headaches or neurological deficits from the syrinx. Surgical decompression of the craniocervical junction is the most widely used procedure. Several surgical techniques have been proposed, but there is no consensus on the best treatment strategy, mainly due to lack of high-quality evidence. The management of the condition during pregnancy, restriction to lifestyle related to athletic activities, and the coexistence of hypermobility require special considerations.

A Presenile Patient with Filar Lipoma Who Developed Tethered Spinal Cord Syndrome Triggered by Lumbar Canal Stenosis

Lumbar canal stenosis (LCS) has been reported as a precipitating factor by which a tethered spinal cord, which is asymptomatic during childhood, develops into tethered cord syndrome (TCS) in adulthood. However, only a few reports on surgical strategies for such cases are available. A 64-year-old woman presented with unbearable pain in the left buttock and dorsal aspect of the thigh approximately 1 year ago. Magnetic resonance imaging showed cord tethering with a filar-type spinal lipoma and LCS due to the thickening of the ligamentum flavum at the L4-5 vertebral level. Five months after the decompressive laminectomy for the treatment of LCS, an untethering surgery was performed at the dural cul-de-sac at the S4 level. The severed end of the filum was elevated rostrally by 7 mm, and the pain subsided postoperatively. This case study shows that surgeries for both lesions should be indicated for adult-onset TCS triggered by LCS.

Updates on Intraoperative Neurophysiology During Surgery for Spinal Dysraphism

Spinal dysraphism is a group of disorders resulting from an embryologic failure of spinal cord development which can lead to a radicular-medullary mechanical stretch that generates vascular compromise and hypoxic-ischemic damage to the nervous structures of the conus-cauda region.Thus, the clinical relevance of the different types of spinal dysraphism is related to the possible neurologic deficits resulting from spinal cord tethering. The clinical presentation is heterogenous: from asymptomatic to very compromised patients. The indications and the time of a detethering surgery are still subject of debate, although there is an agreement on the high standards of treatment that have to be offered by the surgery. Intraoperative neurophysiology (ION) contributes to the safety of tethered cord surgery in reducing the risks of iatrogenic neurological damages.

Does early tethered cord release in occult spinal dysraphism improve urological outcomes? A systematic review

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.

Sacral myolipoma with involuntary contraction causing tethered cord syndrome: illustrative case

BACKGROUND

Spinal lipomas sometimes involve various ectopic tissues originating from the ectoderm, mesoderm, and endoderm in the process of morphological development.

OBSERVATIONS

A 29-year-old male patient with myolipoma of the conus medullaris at the S2 and S3 levels was described. The unusual finding, involuntary muscle contraction, was presented in an operative video and a literature review. In the present case, sacral myolipoma with involuntary contraction caused tethered cord syndrome in adulthood, and untethering surgery resolved continuous buttock and leg pain.

LESSONS

This rare finding is considered a surgical indication for adult patients with myolipoma.

Spinal column shortening for tethered cord syndrome: a systematic review and individual patient data meta-analysis

OBJECTIVE

Tethered cord release (TCR) is the gold standard treatment for tethered cord syndrome (TCS); however, there are significant shortcomings including high rates of retethering, especially in complex and recurrent cases. Spinal column shortening (SCS) is an alternative treatment for TCS intended to avoid these shortcomings. Early studies were limited to case reports and smaller case series; however, in recent years, larger case series and small cohort studies have been conducted. Given the increase in available data, a repeat systematic review and meta-analysis is warranted to assess the safety and efficacy of SCS for TCS.

METHODS

The authors conducted a systematic review using MEDLINE (OVID), Embase (Elsevier), and Web of Science records dating from 1944 to July 2021 to identify all articles investigating SCS for TCS. They performed standard and individual patient data (IPD) meta-analyses, with 2 independent reviewers using PRISMA-IPD guidelines. Primary outcomes were improvement of preoperative clinical symptoms of pain, motor weakness, and bladder and bowel dysfunction, and also surgical complication rate. Secondary outcomes included urodynamic improvement and health-related quality-of-life outcomes determined using patient-reported outcome tools. Individual study quality assessment was performed using a standardized assessment tool for case reports/series, and publication bias was assessed using funnel plot analyses.

RESULTS

The review yielded 15 studies with 191 cases of TCS treated with SCS. IPD were available in 11 studies with 89 cases. The average age at time of surgery was 28.0 years (range 5-76 years). The average follow-up time was 33.2 months (range 7-132 months). Improvement was observed at last follow-up in 60 of 70 (85.7%) patients with preoperative pain, in 38 of 60 (60.3%) patients with preoperative weakness, and in 36 of 76 (47.4%) patients with preoperative bladder or bowel dysfunction. Complications of CSF leak, new neurological deficit, wound infection, or reoperation occurred in 4 of 89 (4.5%) patients.

CONCLUSIONS

SCS may be considered a safe and efficacious treatment option for TCS in children and adults (level C evidence; class IIb recommendation), especially for recurrent and complex cases. Current evidence is likely to be affected by selection and publication bias. Prospective comparative studies of SCS and TCR for TCS are recommended to determine long-term duration of outcomes, long-term safety in skeletally immature children, and exact indications of SCS versus traditional TCR.

Determination of the normal conus medullaris level in term infants: the role of MRI in early infancy

OBJECTIVE

This study aimed to explore the migration process of the conus medullaris (CM) in early infancy using infant MRI and to evaluate the application of MRI for locating the infant CM level.

METHODS

The authors retrospectively analyzed the CM level on the lumbosacral MR images of 26 term infants aged < 3 months who were classified into three groups according to age. The authors numbered the CM level in each patient and analyzed the range and average of the CM level of the cohort. The authors studied the linear correlation between CM level and postnatal days with linear regression analysis, 1-way ANOVA, and the least significant difference test.

RESULTS

The CM level ranged from the superior border of the L1 vertebra to the top third of the L3 vertebra. About 96.2% of infants had CM higher than the superior border of the L3 vertebra. On average, CM was located between the L1-2 intervertebral disc and the inferior border of the L2 vertebra (mean ± SD score 1.64 ± 1.14). The three groups had no significant statistical difference in CM level (F = 1.071 and p = 0.359; groups 1 and 2, p = 0.408; groups 1 and 3, p = 0.170; groups 2 and 3, p = 0.755). CM level had no linear regression correlation with postnatal days within the first month (r2 = 0.061, F = 0.654, p = 0.438) or within the first 3 months (r2 = 0.002, F = 0.056, p = 0.816).

CONCLUSIONS

The CM level reaches the normal adult level by birth in term infants and does not ascend during childhood. On average, the CM was between the L1-2 intervertebral disc and the inferior border of the L2 vertebra in term infants. Considering the possibility of physiologically low-lying CM, the authors agree that normal CM is located above the L3 level in term infants and CM at the L3 level could be equivocal and should be investigated with other clinical data. The study data suggest that MRI is an accurate and valuable method for determining the CM level in term infants.

Intradural view of the spinal cord and dura after three-column osteotomy: illustrative case

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.

Split Cord Malformation in a Thoroughbred Horse

We report a 9-year-old Thoroughbred gelding that had sudden onset lameness of the right forelimb with episodes of lateral decubitus and generalized pain after completion of a normal training session. The clinical signs subsequently became less pronounced with only mild right forelimb lameness. However, after further orthopaedic examination, it developed severe, acute ataxia and paraplegia, the Schiff-Sherrington phenomenon and risus sardonicus. At necropsy, a partial duplication of the cervical spinal cord was identified, consistent with split spinal cord malformation type II or diplomyelia. However, the clinical significance of this finding is not clear.

Surgical pathway proposal for severe paralytic scoliosis in adolescents with myelomeningocele

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.

Posterior Vertebral Column Subtraction Osteotomy for Recurrent Tethered Cord Syndrome: A Multicenter, Retrospective Analysis

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.

Tethered spinal cord syndrome in adults in the MRI era: recognition, pathology, and long-term objective outcomes

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.

Early de-tethering: analysis of urological and clinical consequences in a series of 40 children

PURPOSE

Early de-tethering procedures are performed on spinal dysraphisms to prevent neuro-urological deterioration caused by growth. Partial lipoma removal may cause delayed deterioration by re-tethering, while complete removal may increase the risk of postoperative worsening. The present study evaluates the risk of postoperative deterioration and the protective potential of intraoperative neurophysiological monitoring (IOM), with a special reference to the conus lipomas treated with the radical approach.

METHODS

Forty toddlers (< 24 months) underwent complete perioperative neurological and urological assessment, including urodynamic study (UDS). The dysraphisms were subgrouped according to Pang's classification. IOM was applied in all patients: transcranial motor evoked potentials (tMep) combined with mapping were recorded in all cases while bulbocavernosus reflex (BCR) was evaluable just in 7 cases.

RESULTS

At preoperative evaluation, 11 children already had UDS impairment and 2 had motor disturbances before neurosurgery. At 1-month follow-up, preoperative motor disturbances were stable, 7/11 UDS alterations normalized, and the remaining 4 were stable. At 6-month follow-up, all motor deficits and 8/11 preoperative UDS alterations had improved. Unfortunately, 7 children with previously normal UDS experienced a new impairment after surgery: 2/7 normalized while 5/7 did not recover. This postoperative permanent urodynamic impairment occurred in 4 chaotic lipoma (CLchaos) and in one terminal myelocystocele (TMC) that means a surgical deterioration rate of 22% for the high risk cases.

CONCLUSIONS

This small highly selected series confirms that early de-tethering may stop or revert the spontaneous neuro-urological deterioration: in fact, preoperative UDS impairment was frequent (27.5%) and improved in all the low surgical risk cases (limited dorsal myeloschisis, filar, transitional and dorsal lipomas). On the contrary, in CLchaos and TMC, early de-tethering was unable to revert preoperative UDS impairment, and radical surgery carried a high risk of new neuro-urological deterioration directly caused by the operation. In our experience, IOM had a protective role for motor functions, while it was less effective for the neuro-urological ones, probably due to the anesthesiology regimens applied. In conclusion, among the dysraphisms, CLchoas proved to be the worst enemy that often camouflages at MRI. Affording it without all possible IOM weapons carries a high risk to harm the patient.

Association between filum terminale internum length and pain in Cavalier King Charles spaniels with and without syringomyelia

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.

[TETHERED CORD SYNDROME IN CHILDREN WITH DAYTIME INCONTINENCE]

(Introduction) In tethered cord syndrome, the lower end of the spinal cord is moored to the caudal tissue, causing various neuropathies. Bladder dysfunction often appears early. We herein evaluated children with daytime urinary incontinence in whom tethered cord syndrome was eventually diagnosed. (Method) Eighteen children (9 males and 9 females) with daytime urinary incontinence were enrolled between March 2011 and October 2017. The causes of their urinary incontinence were investigated using spinal MRI and changes in clinical symptoms before and after untethering surgery. (Results) The average age at the first visit was 6.3 years (range: 4-9 years). Urodynamic testing and a voiding cystourethrogram (VCUG) were performed in all cases of refractory daytime incontinence, and all patients with abnormal findings on either test underwent spinal MRI. The diagnosis based on spinal MRI findings was filum lipoma in eight, occult tethered cord syndrome in four, low set conus in four, conus lipoma in one, and sacral meningeal cyst in one, patient. The average observation period after untethering surgery was 66.3 months (range: 22-116 months). All the patients achieved a cure postoperatively. Four patients were treated for nocturnal enuresis by oral medication, and three patients required urological management via clean, intermittent catheterization. (Conclusions) When treating children with daytime continence, one should consider the possibility of tethered cord syndrome, the diagnosis of which can be aided by urodynamic assessment of bladder function.

Intraoperative Neuromonitoring for Tethered Cord Surgery in Infants: Challenges and Outcome

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of intraoperative neuromonitoring (IONM) in surgery for tethered cord in infants.

MATERIALS AND METHODS

The study included 87 infants who underwent surgery for closed spinal dysraphism under IONM. Their preoperative neurological and urological statuses were compared with postoperative status clinically. The study design was prospective, and the study's duration was from January 2011 to February 2020. IONM was performed (TcMEP and direct mapping) with an Xltek Protektor 32 IOM system, Natus Neurology/medical Inc., Middleton, USA. Statistical analysis in the form of χ2 is conducted using SPSS.

RESULTS

Overall, among 87 patients, clinical improvement was seen in 28 (28/29) patients with motor deficits, 17 (17/24) with bladder deficits, and 18 (18/24) with bowel deficits. The monitorability for motor and sphincter was 97.3% and 90.7%, respectively. The sensitivity of IONM in predicting new motor deficit was 100%, whereas the specificity was 100%. The negative predictive value of predicting motor deficit was 100%, with a diagnostic accuracy of 100%. There were no complications in this cohort related to the IONM.

CONCLUSIONS

The study has highlighted that the use of IONM is sensitive in identifying motor injury in infants with reliable outcome correlation. Assessment, monitoring, and outcome correlation of bladder and sphincteric functions are a challenge in this cohort.

Outcome in 32 cases of tethered cord in adults-is intervention justified?

INTRODUCTION

Adults rarely present with tethered cord syndrome, and this review examines whether it is justifiable to perform surgical intervention in this group.

METHODS

Between 2003 and 2017, we performed surgical intervention in 32 adults with tethered cord syndrome. The age range varied from 22 to 65 years. Twenty-six had pain, 20 had motor deficits, and 18 had sensory deficits, whereas 17 presented with sphincter disturbances. Three had undergone surgery for meningomyelocele as infants. Six patients had major spinal deformity in the shape of kyphosis or scoliosis. All patients underwent digital radiographs and MR scans of the whole spine. The oldest with a leaking open meningocele was 41 years old.

RESULTS

The mean follow-up was 3.2 years. Twenty-one out of 26 patients presenting with pain had their VAS scores improve significantly; 14 had motor deficits which improved. However, sensory deficits got better in only 7 out of 18 patients, and sphincter improvement was documented (via urodynamics studies and bladder ultrasound) in only 4 out of 17 patients. In 15 cases, surgery was performed under neurophysiological monitoring, and overall improvement was documented in 11 of these patients compared with 7 of the remaining 17 patients. Surgery for spinal deformity was performed in 6 patients, and deformity correction as well as pain reduction was achieved in all.

CONCLUSION

Surgery leads to significant reduction of pain by untethering and in those with spinal deformity by correction of the same. Improvement in sensory changes and sphincter problems occurred in few patients. Neuromonitoring certainly has improved our results.

Secondary tethered cord syndrome in adult patients: retethering rates, long-term clinical outcome, and the effect of intraoperative neuromonitoring

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.

Surgical Management of Complex Spinal Cord Lipomas : A New Perspective

This review summarises the classification, anatomy and embryogenesis of complex spinal cord lipomas, and describes in some detail the new technique of total lipoma resection and radical reconstruction of the affected neural placode. Its specific mission is to tackle two main issues surrounding the management of complex dysraphic lipomas : whether total resection confers better long term benefits than partial resection, and whether total resection does better than conservative treatment, i.e., no surgery, for asymptomatic lipomas. Accordingly, the 24 years progression-free survival data of the author and colleagues’ series of over 350 cases of total resection are compared with historical data from multiple series (including our own) of partial resection, and total resection data specifically for asymptomatic lesions are compared with the two known series of non-surgical treatment of equivalent patients. These comparisons amply support the author’s recommendation of total resection for most complex lipomas, with or without symptoms. The notable exception is the asymptomatic chaotic lipoma, whose peculiar anatomical relationship with the neural tissue defies even our aggressive surgical approach, and consequently projects worse results (admittedly of small number of cases) than for the other two lipoma subtypes of dorsal and transitional lesions. Prophylactic resection of asymptomatic chaotic lipomas is therefore not currently endorsed.

The use of decompressive segmental sublaminoplasty to treat myelopathy caused by lumbar stenosis in tethered cord syndrome

A 79-year-old woman presented with acute-onset right leg pain in the setting of 3 months of progressive gait deterioration and bilateral leg weakness. On exam she had right lower extremity hyperreflexia and weakness. Lumbar spine magnetic resonance imaging demonstrated L3–L5 central canal stenosis with L4–L5 spondylolisthesis and a previously undiagnosed tethered cord. She underwent minimally invasive left segmental sublaminoplasty at L3–L4 and L4–L5 for spinal cord decompression with onlay arthrodesis resulting in resolution of her radicular pain and improved strength. This is a unique case of lumbar spinal stenosis presenting with myelopathy in the context of a previously asymptomatic and undiagnosed tethered cord.

Structured MRI reporting in spinal dysraphism

Magnetic resonance evaluation of spinal dysraphism can be confusing for inexperienced radiologists and a detailed, step-by-step evaluation of the normal and abnormal imaging findings can help garner the diagnosis. The purpose of this article is to review the existing literature and to provide a comprehensive, structured, template checklist-style format for reporting spinal dysraphism that can help inexperienced radiologists to systematically analyze and report all the significant and ancillary findings in cases of spinal dysraphism and efficiently communicate the findings to the treating physician/surgeon.

Urological presentations of adult primary tethered cord syndrome

AIMS

To investigate the urological presentations of patients initially diagnosed with closed spinal dysraphism in adulthood: adult primary tethered cord syndrome (ApTCS).

METHODS

Patients with ApTCS who underwent subsequent untethering were studied. Urological presentations were evaluated grouped by symptom onset period of either after (group 1) or before (group 2) the completion of physical growth.

RESULTS

Of the 43 patients, median age at diagnosis and initial untethering was 35.5 (18.4-67.2) years. At diagnosis, 90.7% (39/43) had urological symptoms and 18.6% (8/43) initially consulted a urologist without noticeable neurological symptoms. Enuresis was observed in 16.3% (7/43) and common among patients without significant neurological symptoms (62.5%, 5/8). Urgency urinary incontinence and frequency prevailed in group 1. Stress urinary incontinence and straining to void prevailed in group 2. Among 26 patients with pre- and post-operative urodynamics, detrusor overactivity predominated in group 1 and acontractile detrusor predominated in group 2. Glomerular filtration rate ≥90 mL/min/1.73m² was noted in 86.0% (37/43) and 84.9% (73/86) of renal units were morphometrically intact. More patients in group 2 (93.3%) relied on assisted emptying than in group 1 (53.6%).

CONCLUSIONS

In ApTCS, enuresis was prevalent among patients without noticeable neurological symptoms. Over 80% in both groups had favorable renal function. Bladder conditions were different based on symptom onset period. Significantly more patients whose symptoms developed before completion of growth relied on assisted emptying. Proper discerning might be crucial in ApTCS which has a potential of misdiagnosis even in the modern developed era.

Type I split cord malformation and tethered cord syndrome in an adult patient: A case report and literature review

Background:

In a split cord malformation (SCM), the spinal cord is divided longitudinally into two distinct hemicords that later rejoin. This can result in a tethered cord syndrome (TCS). Rarely, TCS secondary to SCM presents in adulthood. Here, we present an adult female with Type I SCM resulting in TCS and a review of literature.

Case Description:

A 57-year-old female with a history of spina bifida occulta presented with a 2-year history of worsening back and left leg pain, difficulty with ambulation, and intermittent urinary incontinence; she had not responded to conservative therapy. Magnetic resonance imaging (MRI) revealed a tethered cord secondary to lumbar type I SCM. The patient underwent an L1–S1 laminectomy for resection of the bony septum with cord detethering. At 2-month follow-up, the patient had improvement in her motor symptoms and less pain. In literature, 25 cases of adult-onset surgically managed SCM with TCS were identified (between 1936 and 2018). Patients averaged 37 years of age at the time of diagnosis, and 56% were female.

Conclusion:

TCS can present secondary to SCM in adulthood and is characterized predominantly by back and leg pain.

Surgical treatment of tethered cord syndrome-comparing the results of surgeries with and without electrophysiological monitoring

PURPOSE

To compare the short- and long-term outcomes after surgical treatment of tethered cord syndrome with and without electrophysiological monitoring.

METHOD

We collected the preoperative data of 102 tethered cord surgeries of 91 patients. We compared the outcomes regarding the presence of intraoperative electrophysiology, the types of surgeries and the preoperative neurological condition. We also analysed the long-term outcomes in the cases of 69 patients.

RESULTS

We found that intraoperative electrophysiology can reduce the perioperative surgical risk significantly (from 9.4 to 2.9%, p < 0.001), and electrophysiology is also beneficial in avoiding long-term progression in 88.7% (p = 0.03341).

CONCLUSION

Tethered cord surgeries are safe and effective. With the use of intraoperative electrophysiology, the risk of postoperative worsening is as low as 2.9%, and long-term progression can be avoided in the majority of the patients.

Surgical management of complex spinal cord lipomas: how, why, and when to operate. A review

This review summarizes the classification, anatomy, and embryogenesis of complex spinal cord lipomas, and it describes in some detail the new technique of total lipoma resection and radical reconstruction of the affected neural placode. Its specific mission is to tackle two main issues surrounding the management of complex dysraphic lipomas: whether total resection confers better long-term benefits than partial resection and whether total resection fares better than conservative treatment-i.e., no surgery-for asymptomatic lipomas. Accordingly, the 24-year progression-free survival data of the author and colleagues' series of over 300 cases of total resection are compared with historical data from multiple series (including the author and colleagues' own) of partial resection, and total resection data specifically for asymptomatic lesions are compared with the two known series of nonsurgical treatment of equivalent numbers of patients. These comparisons amply support the author's recommendation of total resection for most complex lipomas, with or without symptoms. The notable exception is the asymptomatic chaotic lipoma, whose peculiar anatomical relationship with the neural tissue defies even this aggressive surgical approach and consequently projects worse results (admittedly of a small number of cases) than for the other two lipoma subtypes of dorsal and transitional lesions. Prophylactic resection of asymptomatic chaotic lipomas is therefore not currently endorsed.

Secondary sacral tethered cord syndrome after treatment of secondary cervical syringomyelia

A female patient operated at the age of 11 on a pilocytic astrocytoma in the posterior fossa, was re-operated for a recurrence 9 years later. A Torkildsen drain was placed in the 4th ventricle and she remained asymptomatic for 15 years before presenting again with acute hydrocephalus, tonsillar herniation, and a massive cervicothoracic syrinx. The symptoms retreated following craniocervical untethering and decompression. Two weeks later, however, she suffered from debilitating radiculopathy provoked by tethering of the cauda equina. Again, symptoms retreated completely after microsurgical intervention. This combination of a secondary Chiari-like malformation with cervical syringomyelia and tethering of the cauda equina in a single patient as a delayed complication of posterior fossa surgery has not been reported before. Diagnosis and treatment of lower tethered cord syndrome may be obscured and delayed in complex clinical situations. In particular, awareness to symptoms that are not related to syringomyelia is important in patients with a known syrinx and a history of posterior fossa surgery.

Correlation between the severity of myelopathy and cervical morphometric parameters on dynamic magnetic resonance imaging

BACKGROUND

To compare morphometric factors of cervical spine in the cervical stenosis on dynamic and static magnetic resonance imaging. To analyse the relationship between the severity of myelopathy and morphometric parameters.

METHODS

Patients with cervical canal stenosis scanned with MRI in neutral (N), flexion (F) and extension (E) positions were retrospectively reviewed. All cases were evaluated in Nurick and Muhle grades. Following parameters were measured: anterior and posterior length of the cervical cord (aLCC, pLCC), mid-cord distance (L value), cervical cord angle (CCA), cervical lordosis, spine/cord (S/C) angle ratio, spinal cord (SC) area, cerebrospinal fluid (CSF) area, and CSF reserve ratio (CSF/CSF plus SC). Univariate multiple regression for Nurick grade as dependent factor was used.

RESULTS

Sixty-three patients and 34 men, with the mean age of 58.2 ± 11 years, were analysed. Significant differences were found for pLCC, SC area, C lordosis and CCA. The difference between F and E for C lordosis angle was 42.80° ± 14.4 and for CC angle 30.42° ± 9.6. The mean S/C angle ratio was calculated for 1.4 ± 1.3. Nurick grade positively correlated with age (p = 0.041) and S/C angle ratio (p = 0.011), negatively with SC area (p = 0.006) and flexion-extension difference of L value (0.004).

CONCLUSIONS

Severity of myelopathy correlates with age, spinal cord area on extension and reduced mobility of spinal cord. An association between spine/cervical cord angle mismatch and Nurick grade was found.

Adult Versus Pediatric Tethered Cord Syndrome: Clinicoradiological Differences and its Management

Background

Dysraphic lesions in adults, presenting clinically as tethered cord syndrome (TCS), are relatively rare, and their optimal management remains controversial.

Patients and Methods

We performed a retrospective analysis of our pediatric database over a period of last 7 years to focus on the adult TCS. Our aim was to determine the clinicoradiological and etiopathological differences between adult and pediatric patients as well as to determine the results of surgery in adult TCS.

Results

Adult spinal dysraphisms constituted 15.4% of our patients (20 out of 130). Motor weakness, sphincteric dysfunction, and backache (n = 13, 65.0% each) predominated in adults unlike children who presented with subcutaneous swellings (n = 74, 67.6%) followed by motor weakness (n = 40, 46.4%), backache being reported by only three patients. The different pathologic substrates underlying adult dysraphisms were lipomeningocele (n = 8), split cord malformation (total = 7; Type 1: n = 5; Type 2: n = 2), dermal sinus (n = 2), and fatty filum (n = 3). On the other hand, meningomyelocele/meningocele (61, 54.9%) followed by split cord malformation Type 1 and 2 (n = 29, 26.1%) predominated in children. The radiological differences between the two groups were a higher incidence of vertebral body defects (hemivertebrae and butterfly vertebrae) and lack of intracranial anomalies in adults. At a mean follow-up of 20.5 months, the most common symptoms to improve following detethering were pain (11 out of 13, 84.6%) followed by motor weakness (six out of 13, 56.2%) and sphincteric control (7 out of 13, 53.8%).

Conclusion

Most common symptoms to improve following detethering in adult TCS were pain followed by motor weakness. The major radiological differences between these two groups were a higher incidence of vertebral body defects (hemivertebrae and butterfly vertebrae) and lack of intracranial anomalies in adults.

Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child: A case report and literature review

RATIONALE

Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder.

PATIENT CONCERNS

A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis.

INTERVENTIONS

He was operated on successfully and the cervical lordosis and pain resolved.

OUTCOMES

The child recovered well with no tumor recurrence and massive improvement of his life.

LESSONS

The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.

Intraoperative feasibility of bulbocavernosus reflex monitoring during untethering surgery in infants and children

Bulbocavernosus reflex (BCR) monitoring is used to assess the integrity of urinary and bowel function. In this study, we evaluated the feasibility of BCR monitoring during untethering surgery in infants and children to predict postoperative urinary and bowel dysfunction. The records of 22 patients ranging from 4 days to 10 years old (mean 2.7 ± 3.3 years) were reviewed. Anesthesia was maintained by propofol or sevoflurane/opioid without neuromuscular blockade. BCR waveforms induced by electrical stimulation (20-40 mA, train-of-four pulses with 500 Hz) to the penis or clitoris were recorded from bilateral external anal sphincters. To assess the sensitivity and specificity of BCR monitoring, we investigated the association between a significant continuous decrease in BCR amplitude at the end of surgery and postoperative urinary and bowel dysfunction after surgery. Reproducible baseline BCR waveforms were successfully recorded in 20 of 22 patients (90.9%). A significant continuous decrease in BCR amplitude was observed in 8 patients. The results of intraoperative BCR monitoring included three true-positives, twelve true-negatives, five false-positives, and zero false-negatives. Therefore, the sensitivity and specificity of BCR monitoring used to predict postoperative urinary and bowel dysfunction were 100 and 70.6%, respectively. BCR monitoring during untethering surgery in infants and children under general anesthesia was found to be a feasible method to prevent postoperative urinary and bowel dysfunction.

Aggressive Resection of Congenital Lumbosacral Lipomas in Adults: Indications, Techniques, and Outcomes in 122 Patients

OBJECTIVE

The authors reviewed the treatment of adult patients with congenital intraspinal lipomas with total/near-total resection and discussed their preoperative characteristics, prognostic factors, and surgical outcomes.

METHODS

Medical records of 122 adult patients with congenital lumbosacral lipomas undergoing total/near-total resection were systematically analyzed. The cohort was subdivided into 3 groups depending on symptom onset age: group 1 (≤5 years, n = 40), group 2 (>5 years but <18 years, n = 33), and group 3 (>18 years, n = 49). Preoperative and postoperative neurologic status were compared between groups and analyzed as a whole.

RESULTS

The most common symptom was bladder dysfunction (82.0%), followed by constipation (76.2%). At the 3-month follow-up, improvement was noted in most patients presenting with pain (87.2%) and neuropathic ulcers (70.0%). Overall, neurologic status was improved in 73.0% of patients and stabilized in 19.7% of patients. A binary logistic regression model identified shorter preoperative duration (P = 0.013) and preoperative pain (P = 0.005) as independent predictors of postoperative improvement. Neurosurgical complications developed in 16 patients, and wound complications occurred in 2 patients. Two of 3 patients who had recurred symptoms underwent repeated detethering surgery during long-term follow-up.

CONCLUSIONS

Despite longer preoperative duration than the pediatric population, adult patients with lumbosacral lipomas can still benefit from total/near-total resection especially regarding pain and foot ulcers, with low surgery-related morbidity. The long-term advantage of resecting additional lipoma in adults remains a point of discussion.

Spinal Shortening for Recurrent Tethered Cord Syndrome via a Lateral Retropleural Approach: A Novel Operative Technique

Spine shortening via vertebral osteotomy (SSVO) for recurrent tethered cord syndrome (TCS) is a novel surgical technique that avoids the complication profile associated with revision detethering. While SSVO has previously been described via a posterior approach, we describe a lateral retropleural approach for SSVO in recurrent TCS in a 21-year-old female.

Our patient presented with progressive lower extremity weakness, bowel and bladder incontinence, and back pain in the setting of childhood repair of myelomeningocele and two previous detethering procedures. SSVO was offered to the patient as further detethering was deemed to have significant risk. A discectomy at T11-T12 via the lateral retropleural approach was performed, followed by a T12 partial corpectomy removing the vertebral body down to the inferior aspect of the T12 pedicle, followed by the removal of the ipsilateral pedicle. The T10, T11, L1, and L2 pedicle screws were then placed in the prone position and temporary rods were placed for temporary stability, followed by a laminectomy at T12 and a facetectomy for posterior element release. The remaining pedicle was removed, permanent rods were sequentially placed, and spinal column shortening was achieved by compression against the rods. Standing lateral radiographs demonstrated 19 millimeters (mm) of shortening after the intervention. The patient remained at her neurologic baseline postoperatively. At the six-month follow-up, the patient reported decreased lower extremity radicular pain and improved bowel and bladder function.

This operative report demonstrates that SSVO via a lateral retropleural approach is a viable treatment for the recurrence of TCS. The advantages of this minimally invasive approach compared to the posterior approach are direct access to the vertebral body and disc space, avoiding the need to operate around the spinal cord. Further studies are necessary to assess this minimally invasive approach to spinal shortening and to see if a complete minimally invasive approach is possible.