Spinal Column Shortening for Secondary Tethered Cord Syndrome in Children: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (6) ◽  
pp. E168-E168
Author(s):  
Jacob Archer ◽  
Andrew Jea
Keyword(s):  
Spinal Cord ◽  
Spinal Column ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Motor Dysfunction ◽  
Bladder Function ◽  
Neurological Injury ◽  
Leg Length ◽  
Renal Anomalies ◽  
Advantages And Disadvantages

Abstract Tethered cord syndrome is a constellation of signs and symptoms involving sensory and motor dysfunction of the lower extremities, bladder, and bowel. The pathophysiology may be from a mechanical stretch of the distal spinal cord causing deleterious changes in blood supply and metabolism. The standard of care for tethered cord syndrome has been tethered cord release. However, drawbacks of traditional tethered cord release include neurological injury, cerebrospinal fluid leak, and intradural scarring and retethering of the spinal cord (secondary tethering). As such, spinal column shortening was described to avoid these risks.1 We applied spinal column shortening to children and transitional adults with secondary tethered cord syndrome.1 As shown in cadaveric biomechanical studies, the objective of surgery is to shorten by the spinal column by 1.5 to 2.5 cm, to obtain the equivalent relief of traction on the spinal cord and nerve roots as direct circumferential untethering.2 In this video, we present the case of an 11-yr-old boy with a history of VATERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) and tethered cord syndromes manifest as bladder dysfunction. Our patient had segmentation and formation anomalies of the lumbosacral junction, imperforate anus, and leg length discrepancy. He had already undergone multiple tethered cord releases with no durable improvement in bladder function. After discussion of the advantages and disadvantages of spinal column shortening with the patient and his father, we decided to proceed with this treatment alternative. At 9 mo after surgery, the patient has satisfactory clinical and radiographic outcomes. Informed consent was obtained from the parents of the patient.

scholarly journals Spinal column shortening versus revision detethering for recurrent adult tethered cord syndrome: a preliminary comparison of perioperative and clinical outcomes

2020 ◽  
Vol 32 (6) ◽  
pp. 958-964
Author(s):  
Can Zhang ◽  
Chih-Chang Chang ◽  
Praveen V. Mummaneni ◽  
Chenghua Yuan ◽  
Sanjay Dhall ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Blood Loss ◽  
Lower Extremity ◽  
Clinical Outcomes ◽  
Spinal Column ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Bladder Function ◽  
Perioperative Outcomes ◽  
Estimated Blood Loss

OBJECTIVERecurrent tethered cord syndrome (TCS), believed to result from tension on the distal portion of the spinal cord, causes a constellation of neurological symptoms. Detethering surgery has been the traditional treatment for TCS. However, in cases of recurrent TCS, there is a risk of new neurological deficits developing, and subsequent retethering is difficult to prevent. Spinal column shortening has been proposed as an alternative technique to reduce the tension on the spinal cord without incurring the morbidity of revision surgery on the spinal cord. The authors compared the perioperative outcomes and morbidity of patients who were treated with one or the other procedure.METHODSThe medical records of 16 adult patients with recurrent TCS who were treated between 2005 and 2018 were reviewed. Eight patients underwent spinal column shortening, and 8 patients underwent revision detethering surgery. Patient demographics, clinical outcomes, and perioperative factors were analyzed. The authors include a video to illustrate their technique of spinal column shortening.RESULTSWithin the spinal column shortening group, no patients experienced any complications, and all 8 patients either improved or stabilized with regard to lower-extremity and bowel and bladder function. Within the revision detethering group, 2 patients had worsening of lower-extremity strength, 3 patients had worsening of bowel and bladder function, and 1 patient had improvement in bladder function. Also, 3 patients had wound-related complications. The median estimated blood loss was 731 ml in the shortening group and 163 ml in the revision detethering group. The median operative time was 358 minutes in the shortening group and 226 minutes in the revision detethering group.CONCLUSIONSClinical outcomes were comparable between the groups, but none of the spinal column shortening patients experienced worsening, whereas 3 of the revision detethering patients did and also had wound-related complications. Although the operative times and blood loss were higher in the spinal column shortening group, this procedure may be an alternative to revision detethering in extremely scarred or complex wound revision cases.

Posterior vertebral column subtraction osteotomy: a novel surgical approach for the treatment of multiple recurrences of tethered cord syndrome

2009 ◽  
Vol 10 (4) ◽  
pp. 278-286 ◽  
Author(s):  
Patrick C. Hsieh ◽  
Stephen L. Ondra ◽  
Andrew W. Grande ◽  
Brian A. O'Shaughnessy ◽  
Karin Bierbrauer ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Vertebral Column ◽  
Spinal Column ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
The Novel ◽  
Tethered Spinal Cord ◽  
Vertebral Column Resection ◽  
Csf Leakage ◽  
Multiple Recurrences

Recurrent tethered cord syndrome (TCS) has been reported to develop in 5–50% of patients following initial spinal cord detethering operations. Surgery for multiple recurrences of TCS can be difficult and is associated with significant complications. Using a cadaveric tethered spinal cord model, Grande and colleagues demonstrated that shortening of the vertebral column by performing a 15–25-mm thoracolumbar osteotomy significantly reduced spinal cord, lumbosacral nerve root, and terminal filum tension. Based on this cadaveric study, spinal column shortening by a thoracolumbar subtraction osteotomy may be a viable alternative treatment to traditional surgical detethering for multiple recurrences of TCS. In this article, the authors describe the use of posterior vertebral column subtraction osteotomy (PVCSO) for the treatment of 2 patients with multiple recurrences of TCS. Vertebral column resection osteotomy has been widely used in the surgical correction of fixed spinal deformity. The PVCSO is a novel surgical treatment for multiple recurrences of TCS. In such cases, PVCSO may allow surgeons to avoid neural injury by obviating the need for dissection through previously operated sites and may reduce complications related to CSF leakage. The novel use of PVCSO for recurrent TCS is discussed in this report, including surgical considerations and techniques in performing PVCSO.

scholarly journals Pathophysiology of tethered cord syndrome: correlation with symptomatology

2004 ◽  
Vol 16 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Shokei Yamada ◽  
Daniel J. Won ◽  
Shoko M. Yamada
Keyword(s):  
Spinal Cord ◽  
Spinal Column ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Functional Disorder ◽  
Experimental Animals ◽  
Electrophysiological Activity ◽  
Oxidation Ratio ◽  
And Shifts ◽  
Flexion And Extension

Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord. The mechanical cause of TCS is an inelastic structure anchoring the caudal end of the spinal cord that prevents cephalad movement of the lumbosacral cord. Stretching of the spinal cord occurs in patients either when the spinal column grows faster than the spinal cord or when the spinal cord undergoes forcible flexion and extension. Research in patients and experimental animals suggests that there is a link between the clinical dysfunctions that characterize TCS and putative pathophysiological changes that accompany this syndrome. Among these changes are depression of electrophysiological activity and shifts in the reduction/oxidation ratio of cytochrome oxidase. The latter suggests that there is impairment of oxidative metabolism. These putative pathophysiological changes in TCS occur mainly within the lumbosacral cord under excessive tension. The authors discuss the pathophysiology of TCS and examine related symptoms.

scholarly journals Spinal column shortening for tethered cord syndrome associated with myelomeningocele, lumbosacral lipoma, and lipomyelomeningocele in children and young adults

2017 ◽  
Vol 19 (6) ◽  
pp. 703-710 ◽  
Author(s):  
Guillermo Aldave ◽  
Daniel Hansen ◽  
Steven W. Hwang ◽  
Amee Moreno ◽  
Valentina Briceño ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Young Adults ◽  
Spinal Column ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Neurological Deficits ◽  
Csf Leak ◽  
Cord Injury ◽  
Children And Young Adults

OBJECTIVETethered cord syndrome is the clinical manifestation of an abnormal stretch on the spinal cord, presumably causing mechanical injury, a compromised blood supply, and altered spinal cord metabolism. Tethered cord release is the standard treatment for tethered cord syndrome. However, direct untethering of the spinal cord carries potential risks, such as new neurological deficits from spinal cord injury, a CSF leak from opening the dura, and retethering of the spinal cord from normal scar formation after surgery. To avoid these risks, the authors applied spinal column shortening to children and transitional adults with primary and secondary tethered cord syndrome and report treatment outcomes. The authors' aim with this study was to determine the safety and efficacy of spinal column shortening for tethered cord syndrome by analyzing their experience with this surgical technique.METHODSThe authors retrospectively reviewed the demographic and procedural data of children and young adults who had undergone spinal column shortening for primary or secondary tethered cord syndrome.RESULTSSeven patients with tethered cord syndrome caused by myelomeningocele, lipomyelomeningocele, and transitional spinal lipoma were treated with spinal column shortening. One patient with less than 24 months of follow-up was excluded from further analysis. There were 3 males and 4 females; the average age at the time was surgery was 16 years (range 8–30 years). Clinical presentations for our patients included pain (in 5 patients), weakness (in 4 patients), and bowel/bladder dysfunction (in 4 patients). Spinal column osteotomy was most commonly performed at the L-1 level, with fusion between T-12 and L-2 using a pedicle screw-rod construct. Pedicle subtraction osteotomy was performed in 6 patients, and vertebral column resection was performed in 1 patient. The average follow-up period was 31 months (range 26–37 months). Computed tomography–based radiographic outcomes showed solid fusion and no instrumentation failure in all cases by the most recent follow-up. Five of 7 patients (71%) reported improvement in preoperative symptoms during the follow-up period. The mean differences in initial and most recent Scoliosis Research Society Outcomes Questionnaire and Oswestry Disability Index scores were 0.26 and –13%, respectively; minimum clinically important difference in SRS-22 and ODI were assumed to be 0.4% and –12.8%, respectively.CONCLUSIONSSpinal column shortening seems to represent a safe and efficacious alternative to traditional untethering of the spinal cord for tethered cord syndrome.

346 The Utility of Posterior Vertebral Column Subtraction Osteotomies for Tethered Cord Syndrome

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 278-278
Author(s):  
Shashank V Gandhi ◽  
Ahmad Latefi
Keyword(s):  
Spinal Cord ◽  
Preoperative Evaluation ◽  
Spinal Column ◽  
Tethered Cord ◽  
Radicular Pain ◽  
Neurological Injury ◽  
Csf Leak ◽  
Wound Breakdown ◽  
Spinal Cord Herniation ◽  
Pain Symptoms

Abstract INTRODUCTION Detethering of the spinal cord has historically been the treatment of choice for TCS in the setting of spinal dysraphisms. Recurrent TCS occurs 5–80% of patients. Risk of neurological injury, CSF leak, and wound breakdown increase with subsequent procedures. Kokubun et al. described using PVCSO without microsurgical detethering to relieve stretch strain on the spinal cord; however, there is a paucity of literature on its success. Here we describe our experience with PVCSO for TCS. METHODS A prospectively collected database patients with TCS who underwent PVCSO or were being monitored for potential surgery was analyzed. A team of two neurosurgeons evaluated each patient for potential benefit from spinal shortening osteotomies. Preoperative evaluation included MRI and upright radiographs to assess for location and type of tethering and presence of deformity. Single stage posterior PVCSO were conducted at a neutral level rostral to the tethering site, shortening by 10–15mm. When present PVCSOs were concurrently utilized to correct deformities. RESULTS >6 patients were assessed. 4 patients had failed previous microsurgical detethering at least once. 4 patients underwent PVCSO due to worsening of symptoms: 2 with history of myelomeningocele repair and 2 with arachnoid adhesions after spinal subdural hematoma. All 4 had resolution of weakness, numbness, and radicular pain of legs. Incontinence improved in the patient with arachnoid adhesions. There was no worsening of neurological function. 1 patient with spinal cord herniation and scoliosis, had improved radiculopathy from detethering. CONCLUSION In this series all patients who underwent PVCSO for TCS experiences improvement in motor, sensory, and pain symptoms. Indirect relief of in-line strain and stretch on the spinal cord is possible through PVCSO by shortening the spinal column, without high risk of recurrence of symptoms or neurological injury as there is no direct manipulation of neural elements. PVCSO can be utilized for both congenital and acquired TCS.

scholarly journals Posterior vertebral column subtraction osteotomy for the treatment of tethered cord syndrome: review of the literature and clinical outcomes of all cases reported to date

2010 ◽  
Vol 29 (1) ◽  
pp. E6 ◽  
Author(s):  
Patrick C. Hsieh ◽  
Christopher J. Stapleton ◽  
Pavel Moldavskiy ◽  
Tyler R. Koski ◽  
Stephen L. Ondra ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Vertebral Column ◽  
Spinal Column ◽  
Tethered Cord ◽  
Original Description ◽  
Tethered Cord Syndrome ◽  
Initial Release ◽  
Single Posterior Approach ◽  
Cadaveric Model

Tethered cord syndrome (TCS) is a debilitating condition of progressive neurological decline caused by pathological, longitudinal traction on the spinal cord. Surgical detethering of the involved neural structures is the classic method of treatment for lumbosacral TCS, although symptomatic retethering has been reported in 5%–50% of patients following initial release. Subsequent operations in patients with complex lumbosacral dysraphic lesions are fraught with difficulty, and improvements in neurological function are modest while the risk of complications is high. In 1995, Kokubun described an alternative spine-shortening procedure for the management of TCS. Conducted via a single posterior approach, the operation relies on spinal column shortening to relieve indirectly the tension placed on the tethered neural elements. In a cadaveric model of TCS, Grande and colleagues further demonstrated that a 15–25-mm thoracolumbar subtraction osteotomy effectively reduces spinal cord, lumbosacral nerve root, and filum terminale tension. Despite its theoretical appeal, only 18 reports of the use of posterior vertebral column subtraction osteotomy for TCS treatment have been published since its original description. In this review, the authors analyze the relevant clinical characteristics, operative data, and postoperative outcomes of all 18 reported cases and review the role of posterior vertebral column subtraction osteotomy in the surgical management of primary and recurrent TCS.

Spine-shortening vertebral osteotomy in a patient with tethered cord syndrome and a vertebral fracture

2008 ◽  
Vol 9 (1) ◽  
pp. 62-66 ◽  
Author(s):  
Haruo Kanno ◽  
Toshimi Aizawa ◽  
Hiroshi Ozawa ◽  
Takeshi Hoshikawa ◽  
Eiji Itoi ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Vertebral Fracture ◽  
Rare Case ◽  
Tethered Cord ◽  
Conus Medullaris ◽  
Tethered Cord Syndrome ◽  
Bone Union ◽  
Tethered Spinal Cord ◽  
Fracture Fragment ◽  
Loss Of Correction

The authors report a rare case of tethered cord syndrome with low-placed conus medullaris complicated by a vertebral fracture that was successfully treated by a spine-shortening vertebral osteotomy. The patient was a 57-year-old woman whose neurological condition worsened after a T-12 vertebral fracture because a fracture fragment and the associated local kyphotic deformity directly compressed the tethered spinal cord. An osteotomy of the T-12 vertebra was performed in order to correct the kyphosis, remove the fracture fragment, and reduce the tension on the spinal cord. Postoperative radiographs showed the spine to be shortened by 22 mm, and the kyphosis between T-11 and L-1 improved from 23° to 0°. Two years after the surgery, the patient's neurological symptoms were resolved. The bone union was complete with no loss of correction.

Interventional-Related Spine Anatomy

2018 ◽  
pp. 669-678
Author(s):  
Edward Jack Ebani ◽  
Kathryn Dean ◽  
Apostolos John Tsiouris
Keyword(s):  
Magnetic Resonance Imaging ◽  
Computed Tomography ◽  
Spinal Cord ◽  
Vertebral Column ◽  
Spinal Column ◽  
Imaging Findings ◽  
Spinal Nerves ◽  
Advantages And Disadvantages ◽  
Potential Sources ◽  
Magnetic Resonance Imaging Mri

This chapter on interventional-related spine anatomy provides a concise overview of normal spinal anatomy, as well as commonly encountered pathologic conditions, with a particular emphasis on the relevant imaging findings. The introduction outlines potential sources of back pain and their presenting symptomatology. The chapter reviews the main imaging modalities used to evaluate the spine and discusses their specific advantages and disadvantages. The anatomy of the muscles of the vertebral column, the vertebral column itself, and common variations), intervertebral ligaments and discs, vertebral joints, meninges and spinal cord, spinal nerves, and vasculature of the spinal column and spinal cord are reviewed. The discussion includes multiple radiographic, computed tomography (CT), magnetic resonance imaging (MRI), and angiographic images, as well as illustrations to supplement the text.

Minimal tethered cord syndrome: what's necessary to justify a new surgical indication?

2007 ◽  
Vol 23 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Nathan R. Selden
Keyword(s):  
Spinal Cord ◽  
Mr Imaging ◽  
Voiding Dysfunction ◽  
Additional Data ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Surgical Indication ◽  
Clinical Equipoise ◽  
Class Iii ◽  
Clinicopathological Findings

✓Traditionally, surgical division of the terminal filum (filum terminale) has been reserved for patients with imaging-apparent spinal cord tethering. The occurrence of medically refractory voiding dysfunction of neurogenic origin, without magnetic resonance (MR) imaging documentation of abnormality in the spine, has been termed “minimal” tethered cord syndrome (TCS). The rationale for and utility of using surgical division of the terminal filum in the treatment of minimal TCS are unproven. Six studies that involved surgical division of the terminal filum for minimal TCS were identified and reviewed. A seventh study conducted prior to the MR imaging era, in which authors used myelography, was also included. In addition, two investigations of the clinicopathological findings in such cases were analyzed. A tripartite criterion for justifying the introduction of a new surgical indication is proposed and analyzed in light of this evidence. In children with minimal TCS there are definite pathological changes in the terminal filum that are not visible on routine spinal MR imaging. These changes suggest that the pathophysiology of minimal TCS, like TCS that is demonstrated on neuroimaging, may involve abnormal traction on the distal spinal cord. Additional data are needed regarding the sensitivity and specificity of various clinical studies intended to identify children with minimal TCS. All existing data supporting the efficacy of surgery for minimal TCS have been generated by Class III studies. Clinical equipoise exists for this surgical indication, and, therefore, a prospective randomized trial should be completed.

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