Spinal cord detethering without laminectomy or laminotomy

Background: Tethered cord syndrome occurs when there is abnormal tension on the distal spinal cord, which limits its elevation as patients grow. This results in stretching of the neural elements and microvasculature, resulting in both direct and ischemic injury.[7] Animal studies suggest that impairment of oxidative metabolic pathways may contribute to neuronal injury.[7] Associated conditions include myelomeningocele, lipomyelomeningocele, intraspinal lipomas, diastematomyelia, thickened/fatty filum terminale, and trauma.[2] Tethering may be asymptomatic or result in a variety of symptoms including lower extremity weakness/sensory deficits, bowel/bladder dysfunction, scoliosis, pes cavus, and back/leg pain.[6] Early surgical intervention has been shown to improve outcomes and may be performed prophylactically or to prevent symptom progression.[1,3] More specifically, retrospective studies demonstrate that surgical intervention in patients under the age of 2 years is associated with improved outcomes.[5] In some cases, detethering may result in clinical improvement.[3] Case Description: We present a case of a 6-month-old male with a low-lying conus medullaris, lumbar syrinx, mildly abnormal urodynamic studies, and asymmetric utilization of his lower extremities observed during the evaluation of a Y-shaped gluteal cleft. He underwent elective spinal cord detethering via the safe and effective, minimally invasive technique described in the video. The patient’s parents gave informed consent for treatment and video recording. Institutional review board approval was deemed unnecessary. Conclusion: Given the variety of surgical techniques used for cord detethering, this video may assist other surgeons in developing techniques that require little to no compromise of the developing bony spinal column while achieving sufficient release of the spinal cord.[4]

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Spinal lipomas

Neurosurgical FOCUS ◽

10.3171/foc.2001.10.1.4 ◽

2001 ◽

Vol 10 (1) ◽

pp. 1-13 ◽

Cited By ~ 58

Author(s):

Jeffrey P. Blount ◽

Scott Elton

Keyword(s):

Spinal Cord ◽

Surgical Intervention ◽

Spinal Dysraphism ◽

Tethered Cord ◽

Mass Effect ◽

Conus Medullaris ◽

Neurological Deterioration ◽

Bladder Control ◽

History Of ◽

Compressive Myelopathy

Lipomas of the spinal cord are among the most fascinating lesions encountered by the pediatric neurosurgeon. An understanding of spinal lipomas may, however, be difficult because the terminology used to describe the accumulations of spinal fat is confusing, inconsistently applied, and at times contradictory. An anatomical characterization of lipomas may assist in understanding these lesions. Lipomas of the spinal cord are very rare and cause symptoms related to mass effect and secondary compressive myelopathy. Lipomas of the conus medullaris (or lipomyelomeningocele) are the most common form of fatty masses in the spine and can be divided into dorsal, caudal, and transitional forms. These lesions are a manifestation of occult spinal dysraphism and a common cause of the tethered cord syndrome (TCS). The natural history of untreated lipomyelomeningocele, although incompletely understood, appears to be progressive neurological deterioration with loss of bladder control. Timely, careful surgical intervention may prevent significant neurological deterioration and progressive disability in the majority of children harboring these lesions. In surgical intervention the surgeon seeks to disrupt the connection between the fibrofatty mass and underlying cord as well as to reestablish normal anatomical planes. Several intraoperative video segments illustrating lipomyelome-ningocele resection are included in this paper. Lipomas of the terminal filum (fatty filum) are truly occult and are also associated with TCS. Surgical treatment of filum lipomas carries significantly lower risk than that for lipomas of the conus medullaris. Again, the goal of surgery is to disrupt the connection between the abnormal fibrofatty tissue and the underlying spinal cord.

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Pediatric tethered cord syndrome: response of scoliosis to untethering procedures

Journal of Neurosurgery Pediatrics ◽

10.3171/2009.4.peds08463 ◽

2009 ◽

Vol 4 (3) ◽

pp. 270-274 ◽

Cited By ~ 24

Author(s):

Matthew J. McGirt ◽

Vivek Mehta ◽

Giannina Garces-Ambrossi ◽

Oren Gottfried ◽

Can Solakoglu ◽

...

Keyword(s):

Spinal Cord ◽

Cobb Angle ◽

Incidence Rate ◽

Tethered Cord ◽

Tethered Cord Syndrome ◽

Curve Progression ◽

Leg Pain ◽

Lower Extremity Weakness ◽

Factors Associated ◽

Scoliosis Progression

Object Tethered cord syndrome (TCS) is frequently associated with scoliosis in the pediatric population. Following spinal cord untethering, many patients continue to experience progression of spinal deformity. However, the incidence rate, time course, and risk factors for scoliosis progression following tethered cord release remain unclear. The aim of this study was to determine factors associated with scoliosis progression and whether tethered cord release alone would halt curve progression in pediatric TCS. Methods The authors retrospectively reviewed 27 consecutive pediatric cases of spinal cord untethering associated with scoliosis. The incidence rate and factors associated with scoliosis progression (> 10° increased Cobb angle) after untethering were evaluated using the Kaplan-Meier method. Results The mean age of the patients was 8.9 years. All patients underwent cord untethering for lower-extremity weakness, back and leg pain, or bowel and bladder changes. Mean ± SD of the Cobb angle at presentation was 41 ± 16°. The cause of the spinal cord tethering included previous myelomeningocele repair in 14 patients (52%), fatty filum in 5 (18.5%), lipomeningocele in 3 (11%), diastematomyelia in 2 (7.4%), arthrogryposis in 1 (3.7%), imperforate anus with an S-2 hemivertebra in 1 (3.7%), and lipomyelomeningocele with occult dysraphism in 1 (3.7%). Mean follow-up was 6 ± 2 years. Twelve patients (44%) experienced scoliosis progression occurring a median of 2.4 years postoperatively and 8 (30%) required subsequent fusion for progression. At the time of untethering, scoliosis < 40° was associated with a 32% incidence of progression, whereas scoliosis > 40° was associated with a 75% incidence of progression (p < 0.01). Patients with Risser Grades 0–2 were also more likely to experience scoliosis progression compared with Risser Grades 3–5 (p < 0.05). Whereas nearly all patients with Risser Grades 0–2 with curves > 40° showed scoliosis progression (83%), 54% of patients with Risser Grades 0–2 with curves < 40° progressed, and no patients with Risser Grades 3–5 with curves < 40° progressed following spinal cord untethering. Conclusions In this experience with pediatric TCS-associated scoliosis, patients with Risser Grades 3–5 and Cobb angles < 40° did not experience curve progression after tethered cord release. Patients with Risser Grades 0–2 and Cobb angles > 40° were at greatest risk of curve progression after cord untethering. Pediatric patients with TCSassociated scoliosis should be monitored closely for curve progression using standing radiographs after spinal cord untethering, particularly those with curves > 40° or who have Risser Grades 0–2.

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Successful Treatment of Chronic Back and Leg Pain With Lower Than Usual Placement of High-Frequency Spinal Cord Stimulation in a Patient With Uncorrected Tethered Cord: Case Report

Neurosurgery Open ◽

10.1093/neuopn/okab012 ◽

2021 ◽

Vol 2 (2) ◽

Author(s):

Shane Musick ◽

Jessalyn Ferguson ◽

Jan Paul Muizelaar

Keyword(s):

Spinal Cord ◽

Lower Extremity ◽

Spinal Cord Stimulation ◽

High Frequency ◽

Tethered Cord ◽

Conus Medullaris ◽

Leg Pain ◽

Lower Back ◽

Lower Extremity Pain ◽

Lead Placement

ABSTRACT BACKGROUND AND IMPORTANCE Tethered cord syndrome (TCS) often leads to severe back and leg pain. The typical treatment to stall disease progression is untethering surgery, but this is not always effective for pain. Spinal cord stimulation (SCS) is an efficacious treatment for neuropathic pain. However, it has seldom been utilized in TCS cases. Moreover, with cord elongation, ideal paddle placement is not certain. CLINICAL PRESENTATION We present the case of a 77-yr-old male with severe chronic lower-back and lower-extremity pain. Magnetic resonance imaging (MRI) showed severe lumbar spine degenerative changes, along with a previously undiagnosed spina bifida and conus medullaris termination at L5. We felt that SCS would be the best treatment avenue for his chief complaint of pain. Due to cord elongation, we trialed lower placement of the high-frequency (HF)-SCS system at T11-T12, which led to 80% improvement in pain symptoms within 1 wk and ability to walk for the first time in a year. At his first follow-up appointment, the patient endorsed 80% to 90% relief of his lower-back and bilateral lower-extremity pain, which improved to 100% relief at 12 mo at last visit. CONCLUSION Only 4 other reports were identified in the literature utilizing SCS in TCS cases. Our case adds to the limited body of literature that SCS is an effective therapy for pain in TCS and degenerative spine disease. Only 2 other reports employed lower than usual lead placement. Our case demonstrates that lead placement may need to be changed to accommodate the elongated cord.

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

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21497 ◽

2021 ◽

Vol 2 (19) ◽

Author(s):

Zirun Zhao ◽

Saman Shabani ◽

Nitin Agarwal ◽

Praveen V. Mummaneni ◽

Dean Chou

Keyword(s):

Magnetic Resonance Imaging ◽

Spinal Cord ◽

Urinary Incontinence ◽

Spinal Column ◽

Tethered Cord ◽

Leg Pain ◽

Illustrative Case ◽

Resonance Imaging ◽

Intraoperative Visualization ◽

Spinal Cord Tethering

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.

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

Journal of Neurosurgery Spine ◽

10.3171/spi/2008/9/7/062 ◽

2008 ◽

Vol 9 (1) ◽

pp. 62-66 ◽

Cited By ~ 15

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.

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Minimally Invasive Circumferential Spinal Decompression and Stabilization for Symptomatic Metastatic Spine Tumor

Neurosurgery ◽

10.1227/01.neu.0000365270.23815.b1 ◽

2010 ◽

Vol 66 (3) ◽

pp. E620-E622 ◽

Cited By ~ 22

Author(s):

Alexander Taghva ◽

Khan W. Li ◽

John C. Liu ◽

Ziya L. Gokaslan ◽

Patrick C. Hsieh

Keyword(s):

Spinal Cord ◽

Minimally Invasive ◽

Spinal Cord Compression ◽

Surgical Techniques ◽

Cord Compression ◽

Pedicle Screw Fixation ◽

Lower Extremity Weakness ◽

Hardware Failure ◽

Minimally Invasive Surgical ◽

Potential Benefits

Abstract OBJECTIVE Metastatic epidural spinal cord compression is a potentially devastating complication of cancer and is estimated to occur in 5% to 14% of all cancer patients. It is best treated surgically. Minimally invasive spine surgery has the potential benefits of decreased surgical approach–related morbidity, blood loss, hospital stay, and time to mobilization. CLINICAL PRESENTATION A 36-year-old man presented with worsening back pain and lower extremity weakness. Workup revealed metastatic adenocarcinoma of the lung with spinal cord compression at T4 and T5. INTERVENTION AND TECHNIQUE T4 and T5 vertebrectomy with expandable cage placement and T1–T8 pedicle screw fixation and fusion were performed using minimally invasive surgical techniques. RESULT The patient improved neurologically and was ambulatory on postoperative day 1. At the 9-month follow-up point, he remained neurologically intact and pain free, and there was no evidence of hardware failure. CONCLUSION Minimally invasive surgical circumferential decompression may be a viable option for the treatment of metastatic epidural spinal cord compression.

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The Currarino Triad: Neurosurgical Considerations

Neurosurgery ◽

10.1227/01.neu.0000209945.87233.6a ◽

2006 ◽

Vol 58 (5) ◽

pp. 924-929 ◽

Cited By ~ 34

Author(s):

Pieter J. Emans ◽

Jasper van Aalst ◽

Ernest L.W. van Heurn ◽

Carlo Marcelis ◽

Gauke Kootstra ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Canal ◽

Chart Review ◽

Surgical Intervention ◽

Tethered Cord ◽

Retrospective Chart Review ◽

Risks And Benefits ◽

Chiari Type 1 Malformation ◽

Spine Imaging

Abstract OBJECTIVES: The Currarino triad, a relatively uncommon hereditary disorder, is often associated with tethered cord and anterior myelomeningocele. Little is known of the implications of these neuroanatomic malformations or of the neurosurgical attitude. The objective of this study is to identify the spinal cord and meningeal malformations associated with the Currarino triad and to discuss the risks and benefits of surgical intervention. METHODS: We analyzed the spinal cord malformations and the neurosurgical involvement with the Currarino triad by retrospective chart review. RESULTS: The Currarino triad neuroanatomic malformations were identified in five patients. The Currarino triad was associated with a tethered cord in three patients, a myelomeningocele in five patients, a syrinx in two patients, a fistula between the colon and spinal canal in two patients, and an Arnold-Chiari Type 1 malformation in one patient. CONCLUSION: Full spine imaging is required for all patients diagnosed with the Currarino triad. Magnetic resonance imaging of the head should be performed in every patient with neuroanatomic anomalies. Surgery of an anterior myelomeningocele is not necessarily indicated, only in the rare case in which the space-occupying aspect is expected to cause constipation or problems during pregnancy or delivery. Constipation directly after birth is seen in virtually all patients with the triad. Therefore, constipation cannot be used to diagnose a tethered cord syndrome nor indicate tethered cord release. Fistulas between the spinal canal and colon have to be operated on directly.

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

Journal of Neurosurgery Spine ◽

10.3171/2008.10.spine08123 ◽

2009 ◽

Vol 10 (4) ◽

pp. 278-286 ◽

Cited By ~ 20

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.

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

Journal of Neurosurgery Spine ◽

10.3171/2019.12.spine19659 ◽

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.

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Successful treatment of a patient with congenital kyphoscoliosis associated with tethered cord

Journal of Neurosurgery Spine ◽

10.3171/2014.9.spine13528 ◽

2015 ◽

Vol 22 (1) ◽

pp. 64-69 ◽

Cited By ~ 5

Author(s):

Hui-Ren Tao ◽

Tian-Li Yang ◽

Michael S. Chang ◽

Huan Li ◽

Da-Wei Zhang ◽

...

Keyword(s):

Spinal Cord ◽

Tethered Cord ◽

Congenital Scoliosis ◽

Conus Medullaris ◽

Neurological Deficits ◽

Common Finding ◽

Vertebral Column Resection ◽

Apical Vertebra ◽

Shortening Osteotomy ◽

Posterior Spine

Tethered cord is a common finding in congenital scoliosis. The most frequently advocated approach for this condition is to perform prophylactic detethering of the cord before scoliosis corrective surgery. The authors report on a 14-year-old patient with congenital thoracic kyphoscoliosis associated with a tethered cord, who developed progressive paraparesis and was successfully treated by posterior spine shortening osteotomy alone without prophylactic untethering. The patient had a 103° scoliotic curve together with a 93° kyphotic curve with an apical vertebra of T-7. Furthermore, he developed a significant progression of neurological deficits, including weakness of both legs and urinary and bowel incontinence. Preoperative MRI revealed that the spinal cord was entrapped by the apical vertebra and the low-placed conus medullaris was at approximately L-5. A posterior vertebral column resection of T-7 was performed for the purpose of simultaneously correcting the kyphoscoliosis and releasing tension on the tethered cord without a true detethering surgery. The patient's spinal cord function recovered completely from Frankel D to Frankel E by 6 months after the procedure. Evaluation at 31 months after surgery showed maintenance of good curve correction and normal neurological function.

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