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.

Intrathecal endoscopy to enhance the diagnosis of tethered cord syndrome

2010 ◽  
Vol 13 (4) ◽  
pp. 477-483 ◽  
Author(s):  
Kamal R. M. Woods ◽  
Austin R. T. Colohan ◽  
Shokei Yamada ◽  
Shoko M. Yamada ◽  
Daniel J. Won
Keyword(s):  
Spinal Cord ◽  
Mr Imaging ◽  
Open Surgery ◽  
Cauda Equina ◽  
Tethered Cord ◽  
Signs And Symptoms ◽  
Tethered Cord Syndrome ◽  
Diagnostic Study ◽  
Posterior Displacement ◽  
Percutaneous Endoscopy

Object Tethered cord syndrome (TCS) is being diagnosed in an increasing number of adults and late teens. Before referral to neurosurgeons, however, the majority of patients in this group suffers back and leg pain for a long period without a definitive diagnosis. The diagnostic difficulty derives from 2 factors: the signs and symptoms are subtle and easily overlooked, and the combination of an elongated cord and a thickened filum is lacking in 65% of patients. When a patient presents with signs and symptoms typical for TCS but demonstrates no elongated cord or thickened filum on MR imaging, one must search for a more reliable finding to establish a diagnosis of TCS. Based on the authors' earlier surgical experiences, posterior displacement of the terminal filum is consistently found at surgery in all patients with TCS. In previous publications they interpreted this finding as the lower cord and filum traveling along the concave side of the lumbosacral spinal canal to minimize cord tension. In the present prospective study, the authors attempt to confirm posterior displacement of the filum terminale by using intrathecal endoscopy prior to wide exposure of the spinal cord and filum. Further, the stretch test was applied to the terminal filum to evaluate its elasticity. Methods Sixty-eight patients with signs and symptoms as well as MR imaging studies indicative of TCS underwent endoscopic examination of the filum and cauda equina. After lumbar or sacral laminectomy, a flexible endoscope was inserted through a small dural and arachnoid incision into the subarachnoid space. The filum and cauda equina fibers were identified. Once the dura mater and arachnoid were opened widely, a stretch test was done to confirm filum inelasticity. In 3 patients, percutaneous endoscopy was also performed before open surgery to determine its applicability as compared with the open method. Results On inserting the endoscope into the intrathecal space, the filum was immediately identified medioposterior to the cauda equina fibers in all 68 patients. The stretch test revealed a lack of filum elasticity in all patients. Preoperative percutaneous endoscopy was equally effective in identifying the position of the filum. Conclusions Currently, endoscopic identification of the posteriorly displaced filum, which was confirmed at open surgery, is the essential diagnostic study for TCS or the tethered spinal cord. Furthermore, the stretch test of the filum proves its inelasticity, and filum sectioning leads to ascension and relaxation of the caudal spinal cord. These results can be linked to the impaired oxidative metabolism of the lumbosacral cord under excessive tension and to the metabolic and neurological improvements seen after filum sectioning.

scholarly journals Treatment of terminal syringomyelia in association with tethered cord syndrome: clinical outcomes with and without syrinx drainage

2000 ◽  
Vol 8 (3) ◽  
pp. 1-6 ◽  
Author(s):  
Kaan Erkan ◽  
Faruk Unal ◽  
Talat Kiris ◽  
Turan Karalar
Keyword(s):  
Spinal Cord ◽  
Clinical Outcome ◽  
Mr Imaging ◽  
Tethered Cord ◽  
Clinical Results ◽  
Tethered Cord Syndrome ◽  
Treatment Groups ◽  
Sensory Deficits ◽  
Group I

Object Current use of magnetic resonance (MR) imaging has led to increased awareness of the frequency of terminal syringomyelia in patients with tethered cord syndrome. However, that the surgical treatment of terminal syringomyelia is necessary remains unclear. In this study the authors attempted to assess the clinical impact, if any, brought after syrinx decompression on the clinical outcome of tethered cord syndrome. Methods They randomly assigned 30 cases of pediatric tethered cord into two treatment groups: those in whom an untethering procedure was performed (Group I) and those in whom this procedure was combined with syrinx decompression (Group II). The 1-year follow-up clinical results obtained in the two groups, in correlation with MR imaging findings, were compared to evaluate the benefit of added syrinx drainage. Clinical follow-up evaluation revealed that surgical drainage of the syrinx, when combined with spinal cord untethering, resulted in better outcomes in terms of resolution of sensory deficits (p = 0.036) and bladder dysfunction (p = 0.05). The improvement in clinical outcome correlated with the radiologically documented resolution of the syrinx cavity; however, response rates of symptoms differed for each tethering subgroup. Conclusions Preliminary results of this study indicated that terminal syringomyelia should be considered as a comorbidity that contributes to the clinical outcome of patients with tethered cord syndrome. A better clinical outcome is achieved following successful decompression of the syrinx in addition to untethering the spinal cord. These findings emphasize the importance of recognizing, evaluating, and treating this pathological entity.

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.

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 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.

scholarly journals Tethered cord syndrome with spina bifida aperta in cats: two case reports of different types

2017 ◽  
Vol 3 (1) ◽  
pp. 205511691770806 ◽  
Author(s):  
Masahiro Tamura ◽  
Takashi Oji ◽  
Satoshi Une ◽  
Makiko Mukaino ◽  
Tatsuro Bekki ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Urinary Incontinence ◽  
Spina Bifida ◽  
Tethered Cord ◽  
Tethered Cord Syndrome ◽  
Tethered Spinal Cord ◽  
Dural Sac ◽  
Spina Bifida Aperta ◽  
Different Types ◽  
Progressive Paraparesis

Case summary Two castrated male cats, aged 8 months old (case 1) and 10 months old (case 2), showed a history of progressive paraparesis, an over-reaching pelvic limb gait, urinary incontinence and a palpable dermoid fistula. In case 1, the fistula was connected to the dural sac on the conus medullaris, and the tethered spinal cord was retracted caudally. In case 2, the tubular structure was connected to the dural sac on the thoracic spinal cord, and the tethered spinal cord was retracted dorsally. Tethered cord syndrome secondary to spina bifida aperta was suspected in both cats. Excision of the fistula and release of the tethered spinal cord was performed. A histopathological examination confirmed the diagnosis of a meningomyelocele in case 1 and a meningocele in case 2. Paraparesis improved postoperatively in both cats. However, urinary incontinence in case 1 remained partially unresolved. Relevance and novel information This is the first report to describe the imaging characteristics, surgical treatments and outcomes of two different types of tethered cord syndrome with spina bifida aperta in cats. Tethered cord syndrome with spina bifida aperta needs to be included in the differential diagnosis of slowly progressive paraparesis in younger cats with or without vesicorectal failure and a palpable dermoid fistula.

Tethered cord syndrome in adults

2011 ◽  
Vol 15 (3) ◽  
pp. 258-270 ◽  
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.

Evaluation of anorectal function in patients with tethered cord syndrome: saline enema test and fecoflowmetry

2003 ◽  
Vol 98 (3) ◽  
pp. 251-257 ◽  
Author(s):  
Hiroyuki Kayaba ◽  
Tatsuzo Hebiguchi ◽  
Yasunobu Itoh ◽  
Hiroaki Yoshino ◽  
Masaru Mizuno ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Fecal Incontinence ◽  
Contractile Activity ◽  
Tethered Cord ◽  
Anorectal Function ◽  
Tethered Cord Syndrome ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Untethering Surgery ◽  
Fine Print

Object. Disturbance in anorectal function is a major factor restricting the activities of daily living in patients with spinal cord disorders. To detect changes in anorectal motilities due to a tethered spinal cord, anorectal functions were evaluated using a saline enema test and fecoflowmetry before and after patients underwent untethering surgery. Methods. The bowel functions in five patients with a tethered cord syndrome (TCS) were evaluated by performing a saline enema test and fecoflowmetry. The contractile activity of the rectum, the volume of infused saline tolerated in the rectum, anal canal pressure, and the ability to evacuate rectal content were examined. The characteristic findings in anorectal motility studies conducted in patients with TCS were a hyperactive rectum, diminished rectal saline-retention ability, and diminished maximal flow in saline evacuation. A hyperactive rectum was considered to be a major contributing factor to fecal incontinence. In one asymptomatic patient diminished anal squeezing pressure was exhibited and was incontinent to liquid preoperatively, but recovered after surgery. Two patients who underwent surgery for myeloschisis as infants complained of progressive fecal incontinence when they became adolescents. In one patient fecal incontinence improved but in another patient no improvement was observed after untethering surgery. Conclusions. Fecodynamic studies allow the detection of neurogenic disturbances of the anorectum in symptomatic and also in asymptomatic patients with TCS. More attention should be paid to the anorectal functions of patients with TCS.

scholarly journals Automatic segmentation of spinal cord diffusion MR Images for disease location finding

2019 ◽  
Vol 15 (3) ◽  
pp. 1313
Author(s):  
Sk Hasane Ahammad ◽  
V. Rajesh ◽  
A. Neetha ◽  
Sai Jeesmitha. B ◽  
A. Srikanth
Keyword(s):  
Spinal Cord ◽  
Mr Imaging ◽  
Additional Data ◽  
Dispersion Coefficient ◽  
Automatic Segmentation ◽  
Planar Imaging ◽  
Mr Images ◽  
Location Finding ◽  
Disease Location ◽  
Symptomatic Effect

<p>Dissemination weighted MR imaging may build the affectability and explicitness of MR imaging for certain pathologic states of the spinal rope yet is once in a while performed as a result of a few specialized issues. We consequently tried a novel stage explored turn reverberation dispersion weighted interleaved reverberation planar imaging arrangement in seven sound volunteers and six patients with intramedullary injuries. We performed dispersion weighted MR imaging of the spinal string with high spatial goals. Distinctive examples of dissemination irregularities saw in patient investigations bolster the conceivable symptomatic effect of dispersion weighted MR imaging for ailments of the spinal string. MR imaging has turned into the system of decision for imaging the spinal rope on account of a high affectability for pathologic intra medullary changes. In any case, the explicitness of anomalies oftentimes lingers behind when utilizing just regular MR arrangements. Dissemination weighted MR imaging guarantees to supply additional data in light of trademark changes of the clear dispersion coefficient, for example, those showed in intense ischemia, tumors, or sores related among numerous sclerosis. To date, the indicative commitment of dispersion weighted MR imaging has been concerted essentially in the cerebrum since dissemination weighted MR imaging of the spine is in detail every one the more requesting. Both the little size of the spinal rope and movement-initiated antiquities must be considered. We in this manner built up another examination strategy and tried its unwavering quality and potential for adding to the symptomatic workup of patients with spinal rope indications.</p>

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