Tethered cord release: a long-term study in 114 patients

Object All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008. Methods Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain. Results Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month–23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation. Conclusions Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.

Download Full-text

492 THE BRINDLEY BLADDER STIMULATOR IMPROVES LONG TERM URINARY CONTINENCE AND DECREASES URINARY TRACT INFECTIONS IN COMPLETE SPINAL CORD INJURED PATIENTS AS COMPARED TO A MATCHED CONTROL GROUP

European Urology Supplements ◽

10.1016/s1569-9056(09)60489-9 ◽

2009 ◽

Vol 8 (4) ◽

pp. 243

Author(s):

P.P. Den Hollander ◽

F.M.J. Martens ◽

G.J. Snoek ◽

E.L. Koldewijn ◽

P.E. Van Kerrebroeck ◽

...

Keyword(s):

Spinal Cord ◽

Urinary Tract ◽

Matched Control ◽

Urinary Continence ◽

Control Group ◽

Matched Control Group ◽

Tract Infections ◽

Injured Patients ◽

Spinal Cord Injured

Download Full-text

Posttraumatic spinal cord tethering and syringomyelia: surgical treatment and long-term outcome

Journal of Neurosurgery Spine ◽

10.3171/2009.4.spine09333 ◽

2009 ◽

Vol 11 (4) ◽

pp. 445-460 ◽

Cited By ~ 43

Author(s):

Scott P. Falci ◽

Charlotte Indeck ◽

Daniel P. Lammertse

Keyword(s):

Spinal Cord ◽

Spinal Injury ◽

Treatment Center ◽

Term Outcome ◽

Repeat Surgery ◽

Long Term Outcome ◽

Progressive Myelopathy ◽

Cord Injury ◽

Spinal Cord Tethering

Object Permanent neurological loss after spinal cord injury (SCI) is a well-known phenomenon. There has also been a growing recognition and improved understanding of the pathophysiological mechanisms of late progressive neurological loss, which may occur after SCI as a result of posttraumatic spinal cord tethering (SCT), myelomalacia, and syringomyelia. A clinical study of 404 patients sustaining traumatic SCIs and undergoing surgery to arrest a progressive myelopathy caused by SCT, with or without progressive myelomalacia and cystic cavitation (syringomyelia) was undertaken. Both objective and subjective long-term outcomes were evaluated. To the authors' knowledge, this is the first series of this size correlating long-term patient perception of outcome with long-term objective outcome analyses. Methods During the period from January 1993 to November 2003, 404 patients who had previously sustained traumatic SCIs underwent 468 surgeries for progressive myelopathies attributed to tethering of the spinal cord to the surrounding spinal canal, with or without myelomalacia and syrinx formation. Forty-two patients were excluded because of additional pathological entities that were known to contribute to a progressive myelopathy. All surgeries were performed by the same neurosurgeon at a single SCI treatment center and by using a consistent surgical technique of spinal cord detethering, expansion duraplasty, and when indicated, cyst shunting. Results Outcome data were collected up to 12 years postoperatively. Comparisons of pre- and postoperative American Spinal Injury Association sensory and motor index scores showed no significant change when only a single surgery was required (86% of patients). An outcome questionnaire and phone interview resulted in > 90% of patients self-assessing arrest of functional loss; > 50% of patients self-assessing improvement of function; 17 and 18% self-assessing improvement of motor and sensory functions to a point greater than that achieved at any time postinjury, respectively; 59% reporting improvement of spasticity; and 77% reporting improvement of hyperhidrosis. Conclusions Surgery for spinal cord detethering, expansion duraplasty, and when indicated, cyst shunting, is a successful treatment strategy for arresting a progressive myelopathy related to posttraumatic SCT and syringomyelia. Results suggest that surgery leads to functional return in ~ 50% of patients, and that in some patients posttraumatic SCT limits maximal recovery of spinal cord function postinjury. A patient's perception of surgery's failure to arrest the progressive myelopathy corresponds closely with the need for repeat surgery because of retethering, cyst reexpansion, and pseudomeningocele formation.

Download Full-text

ТREATMENT OF STENOSIS OF THE PYLORIC BULBAR ZONE OF ULCERATIVE GENESIS USING MINIMALLY INVASIVE SURGERY

Kharkiv Surgical School ◽

10.37699/2308-7005.2.2020.33 ◽

2020 ◽

pp. 167-175

Author(s):

O. M. Babii ◽

S. A. Tarabarov ◽

N. V. Prolom ◽

B. F. Shevchenko ◽

A. A. Galinsky

Keyword(s):

Surgical Treatment ◽

Minimally Invasive ◽

Postoperative Period ◽

Clinical Signs ◽

State Institution ◽

Disease Recurrence ◽

Control Group ◽

Surgical Interventions ◽

Remote Observation

Summary. Purpose: to improve the results of surgical treatment of stenosis of the pyloroduodenal zone of ulcerative origin through the use of minimally invasive laparoendoscopic interventions. Material and methods. In the Department of Surgery of the Digestive Organs of the State Institution “Institute of Gastroenterology of the NAMS of Ukraine” for 2014-2019, 114 patients with stenosis of the pyloroduodenal zone of ulcerative origin were examined. Of these, 35 — with compensated stenosis, 57 — with subcompensated, 22 — with decompensated stenosis. The average age (45.3±5.2) years. The control group consisted of 20 healthy individuals. All patients underwent surgical treatment using minimally invasive and traditional surgical interventions. Results and discussion. During the study, known indications were clarified and new indications for performing endoscopic balloon pyloroduodenoplasty and combined laparoendoscopic intervention were clarified. Complications in the immediate postoperative period occurred in 1 patient (1.04%) in the form of perforation of the dilated zone. In patients after the traditional laparotomy surgery, the average postoperative period was (15 ± 2) days. Complications in the immediate postoperative period occurred in 2 patients (11.1 %) in the form of bleeding and leaks in the pyloroplasty zone, which required repeated surgical treatment. Тhere were no fatal cases. The remote observation period was 7-22 months. Endoscopic, radiological and clinical signs of recurrence of peptic ulcer and stenosis were not detected. Conclusions. The method of minimally invasive endoscopic and combined laparoendoscopic interventions in the treatment of stenosis of the pyloroduodenal zone of ulcerative genesis is characterized by a minimal number of complications, has good efficacy indicators and the absence of disease recurrence in the long-term period.

Download Full-text

Spinal development and spinal dysraphism

Oxford Textbook of Neurological Surgery ◽

10.1093/med/9780198746706.003.0085 ◽

2019 ◽

pp. 983-992

Author(s):

Dominic Thompson

Keyword(s):

Spinal Cord ◽

Spinal Dysraphism ◽

Radical Resection ◽

Management Plan ◽

Congenital Disorders ◽

Spinal Cord Development ◽

Precise Diagnosis ◽

Over Time ◽

Spinal Cord Tethering

The term spinal dysraphism encompasses a group of congenital disorders of spinal cord development. This potentially confusing array of conditions is best understood from an embryological perspective, and a unifying method of classification is presented. Spinal dysraphism is associated with neurological, urological, and orthopaedic deficits, these may be present at birth or may evolve over time due to the effects of spinal cord tethering. Precise diagnosis is essential to formulating an appropriate surgical management plan in order to optimize long-term neurological outcome. Contemporary and controversial surgical advances in the field are discussed including electrophysiology directed radical resection for spinal lipomas and antenatal surgery for myelomeningocele.

Download Full-text

Tethered cord syndrome in adults

Journal of Neurosurgery Spine ◽

10.3171/2011.4.spine10504 ◽

2011 ◽

Vol 15 (3) ◽

pp. 258-270 ◽

Cited By ~ 50

Author(s):

Jörg Klekamp

Keyword(s):

Spinal Cord ◽

Tethered Cord ◽

Tethered Cord Syndrome ◽

Neurological Deficits ◽

Short Term ◽

Group A ◽

The Mean ◽

Group B

Object The treatment of tethered cord syndromes in adults is discussed regarding the natural history and surgical indications. The author analyzes data obtained in patients who were diagnosed with a tethered cord in adulthood and either underwent surgical or conservative therapy between 1991 and 2009. Methods Since 1991, data obtained in 2515 patients with spinal cord pathologies were entered into the spinal cord database, and prospective follow-up was performed through outpatient visits and questionnaires. Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. The mean age of the patients was 46 ± 13 years (range 23–74 years) and the mean follow-up duration was 61 ± 62 months. Two groups were distinguished based on the absence (Group A, 43 patients) or presence (Group B, 42 patients) of an associated lipoma or dysraphic cyst (that is, dermoid, epidermoid, or neurenteric cyst). Surgery was recommended for patients with symptoms only. Short-term results were determined within 3 months of surgery, whereas long-term outcomes (clinical recurrences) were evaluated using Kaplan-Meier statistics. Results For all patients, pain was the most common major complaint. Severe neurological deficits were rare. In Group A, 20 of 43 patients underwent surgery, whereas in Group B 23 of 42 patients underwent surgery. Among individuals who did not undergo surgery, 17 patients refused surgery and 25 patients underwent recommended conservative treatment. Short-term postoperative results indicated a significant improvement of pain and a stabilization of neurological symptoms. Long-term results showed a good prognosis in patients in whom first-time (that is, nonrevision) surgery achieved successful untethering, with a 10-year rate of neurological stabilization in 89% of Group A and a 10-year rate of neurological stabilization in 81% of Group B patients. The benefit of secondary operations in Group B was limited, with eventual clinical deterioration occurring in all patients within 10 years. For patients treated conservatively, follow-up information could be obtained in 33 of 42 patients. Twenty-eight patients remained in stable clinical condition. Only 5 of the conservatively treated patients experienced clinical deterioration over time; in 4 of these individuals with deterioration, surgery had been recommended but was refused by the patient. The clinical recurrence rate in all conservatively treated patients was 21% after 10 years. With a recommendation for surgery this figure rose to 47% within 5 years. Conclusions Surgery in adult patients with a tethered cord syndrome should be reserved for those with symptoms. In surgically treated patients, pain relief can often be achieved, and long-term neurological stabilization tends to persist more often than it does in conservatively treated patients. A conservative approach is warranted, however, in adult patients without neurological deficits. Revision surgery in patients with complex dysraphic lesions should be performed in exceptional cases only.

Download Full-text

Spinal Cord Tethering, a Very Rare Cause of Cauda Equina Syndrome after Lumbar Disk Surgery: A Case Report

Prague Medical Report ◽

10.14712/23362936.2020.5 ◽

2020 ◽

Vol 121 (1) ◽

pp. 49-54

Author(s):

Alireza Tabibkhooei ◽

Farid Kazemi ◽

Foad Kazemi ◽

Morteza Taheri

Keyword(s):

Spinal Cord ◽

Case Report ◽

Cauda Equina Syndrome ◽

Treatment Options ◽

Cauda Equina ◽

Tethered Cord ◽

Young Lady ◽

Lumbar Disk ◽

Lumbar Disk Surgery ◽

Spinal Cord Tethering

Tethered cord syndrome (TCS) may rarely remain asymptomatic until degenerative or nondegenerative lumbar diseases superimpose in adulthood and expose the hidden anomaly. In such cases, different treatment options can be selected and simultaneous detethering might be considered too. We are reporting an undiscovered TCS in a young lady who underwent lumbar diskectomy due to symptomatic disk extrusion and suffered complete cauda equina syndrome (CES), postoperatively.

Download Full-text

Effect of Phosphate Supplements on Soft-Tissue Calcification and Bone Turnover

Clinical Science ◽

10.1042/cs0420289 ◽

1972 ◽

Vol 42 (3) ◽

pp. 289-299 ◽

Cited By ~ 27

Author(s):

Jenifer Jowsey ◽

P. Balasubramaniam

Keyword(s):

Soft Tissue ◽

Soft Tissues ◽

Control Diet ◽

Control Period ◽

Control Group ◽

Soft Tissue Calcification ◽

Term Study ◽

Tissue Calcification ◽

Long Term Study

1. The short- and long-term effects of oral phosphate supplements were studied in two groups of adult rabbits. 2. In the short-term study, compared with control animals, the bones of phosphate-supplemented rabbits showed a greater degree of porosity, and defects in the tibia created at the beginning of the study were replaced with bone tissue containing many areas of resorption. There was an increase in retention of 85Sr in the hard and soft tissues, particularly in the kidney and thoracic aorta. 3. In the long-term study, a second group of rabbits received a low calcium and phosphate intake during the control period; half of this group were then fed a low dosage of supplemental phosphate while the remaining half remained on the control diet. After a period of 6 months the bones of phosphate-supplemented animals showed increased porosity and there was an increase in 85Sr retention by the kidney compared with the control group. 4. Phosphate supplementation appears to result in secondary hyperparathyroidism and to cause soft-tissue calcification.

Download Full-text

Pathophysiology of adult tethered cord syndrome: review of the literature

Neurosurgical FOCUS ◽

10.3171/2010.3.focus1080 ◽

2010 ◽

Vol 29 (1) ◽

pp. E2 ◽

Cited By ~ 17

Author(s):

William R. Stetler ◽

Paul Park ◽

Stephen Sullivan

Keyword(s):

Spinal Cord ◽

Blood Flow ◽

Pediatric Patients ◽

Pediatric Population ◽

Tethered Cord ◽

Tethered Cord Syndrome ◽

Tethered Spinal Cord ◽

Spinal Cord Blood Flow ◽

Pubmed Database ◽

Spinal Cord Tethering

Object Tethering of the spinal cord has been a recognized cause of neurological symptoms in pediatric patients and is increasingly being recognized as a cause of symptoms in adults as well. The pathophysiology surrounding spinal cord tethering has begun to be understood in the pediatric population but is still unclear in adult patients. Methods Using a PubMed database literature search, the authors reviewed the pathology and pathophysiology surrounding the tethered spinal cord, focusing particularly on the pathophysiology of adult tethered cord syndrome (TCS). Results Experimental data obtained in pediatric patients at surgery and in animal models indicate that spinal cord tethering causes a reduction in spinal cord blood flow and dysfunction of neuronal mitochondrial terminal oxidase. Retrospective analyses of patients undergoing surgery for adult TCS show that many adults developed symptoms following an event that could stretch the spinal cord, while others did not. Many patients also were found to have structural lesions in addition to a tethered spinal cord at diagnosis. Conclusions Both adult and pediatric TCSs are likely the result of a relative lack of blood flow to the spinal cord, causing dysfunction in mitochondrial oxidative phosphorylation. The likely reason the syndrome present later and differently in adults is that a secondary threshold of tension or a cumulative effect of repetitive, transient tension is placed on the cord before symptoms are recognized.

Download Full-text

Congenital tethered spinal cord syndrome in adults

Journal of Neurosurgery ◽

10.3171/jns.1998.88.6.0958 ◽

1998 ◽

Vol 88 (6) ◽

pp. 958-961 ◽

Cited By ~ 76

Author(s):

Bermans J. Iskandar ◽

Benjamin B. Fulmer ◽

Mark N. Hadley ◽

W. Jerry Oakes

Keyword(s):

Spinal Cord ◽

Tethered Cord ◽

Tethered Cord Syndrome ◽

Early Surgery ◽

Split Cord Malformation ◽

Tethered Spinal Cord ◽

Content Type ◽

Fine Print

Object. The management of tethered spinal cord syndrome with onset of symptomatology occurring in adulthood remains controversial, although the necessity of early surgery in the pediatric tethered cord syndrome population is well established. To ascertain the results of surgery in adult patients with this anomaly, the authors undertook a retrospective review of 34 cases. Methods. The authors studied the hospital records of 34 consecutive patients who presented in adulthood with tethered cord syndrome and conducted follow-up phone interviews with 28 of them. The population consisted of 12 men and 22 women, ranging in age from 18 to 70 years (mean 34 years). The most common presenting feature was pain, followed by weakness and incontinence. All patients underwent surgery. The most common operative findings were tight filum terminale, split cord malformation, and lipomyelomeningocele, paralleling those observed in pediatric studies. Long-term surgical results and patient outcome ratings were encouraging. After a mean clinical follow-up period of 4 years, significant improvement occurred in 22 of 27 patients presenting with pain, 13 of 27 patients with motor or sensory dysfunction, and 11 of 18 patients with bowel and bladder disturbance. In addition, telephone interviews were obtained after a period of 8.6 years. Twenty-two (79%) of 28 patients called the operation a long-term success; 21 (75%) of 28 patients believed that they had significant postoperative improvement (and not just stabilization) in pain and/or neurological function. Surgical complications were generally minor. Nineteen (86%) of 22 employed patients returned to work after surgery. Two (33%) of six patients who were not employed before surgery worked full time postoperatively. Only two of the 28 patients interviewed had received Workers' Compensation benefits; both of these had good outcomes and returned to work. Conclusions. Tethered spinal cord syndrome in adults is an uncommon entity that can become symptomatic. Although surgery in adults involves greater risk of neurological injury than in children, it is a low-risk procedure with encouraging results. Because neurological deficits are generally irreversible, early surgery is recommended.

Download Full-text