Spinal dysraphism

Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery

INTRODUCTION AND OBJECTIVES

Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery.

MATERIALS AND METHODS

We conducted a single-center, double-blind, randomized -controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone (CP-A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP-A group (n = 36, 50%) and CP+A group (n = 36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position + dose of acetazolamide 20 mg/kg/day in 3-4 divided doses for 7 days), and CP-A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide).

RESULTS

Baseline characteristics between the two groups showed no significant differences: Sex (P < .637), Age (P < .988) and previous CNS operation at other location besides the spine (P < .496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36 (11.11%) of CP-A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081-2.748; OR = 0.471; P < .402; Adjusted P < .247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P < .489) and type of operation (P < .465).

CONCLUSION

Acetazolamide has no positive effect in controlling CSF leak after dural opening/dural tear in adult patients who undergo spinal surgery, when we considered alongside the one-week prone position. Therefore, acetazolamide administration may not be essential for postoperative spinal surgery for dural tear. Prospective studies involving a larger sample size may be needed to track long-term acetazolamide complications on patients with CSF leak.

Dermal Sinus Tract associated with Type I and Type II Split Cord Malformation

The dermal sinus tract of the spine is associated with other occult spinal dysraphisms, such as the split cord malformation (diastematomyelia) in a 40% of the cases and embryologically is not clearly defined if the dermal sinus and split cord malformation have origin in gastrulation or late primary neurulation, but the most accepted theory of the dermal sinus tract consists in early incomplete disjunction, which explains the relation with other spinal dysraphisms. Here, we present two cases, with a dermal sinus tract of the spine associated with Type I and Type II split cord malformation.

Randomized clinical trial of acetazolamide administration and/or prone positioning in mitigating wound complications following untethering surgeries

OBJECTIVE No evidence-based guideline has been approved for the postoperative management of pediatric patients with tethered cord syndrome (TCS). The purpose of this randomized clinical trial was to evaluate the effectiveness of prone positioning and acetazolamide administration on complication rates following spinal cord untethering surgeries. METHODS From October 2012 to February 2015, patients with a primary diagnosis of TCS who were admitted to the Children's Medical Center Hospital of Iran were randomly allocated to 1 of 4 intervention modality groups postoperatively: 1) Group A, acetazolamide administration for 10 days; 2) Group B, prone positioning for 10 days; 3) Group C, acetazolamide administration and prone positioning for 10 days; and 4) Group D, no intervention. CSF leakage, CSF collection, wound dehiscence, operative site infection, and secondary surgical wound repair were considered failure. RESULTS A total of 161 patients were enrolled in this study (Group A, n = 39 [24.2%]; Group B, n = 41 [25.5%]; Group C, n = 39 [24.2%]; and Group D, n = 42 [26.1%]). The overall failure rate was 12.42% (20 patients). Complication rates through pooled analyses were as follows: CSF leakage (n = 9, 5.6%), CSF collection (n = 12, 7.5%), wound dehiscence (n = 2, 1.2%), and infection of operation site (n = 3, 1.9%). Two patients (1.2%) required surgical secondary wound repair due to complications. CSF leakage and collection rates were significantly lower in patients who underwent prone positioning (p = 0.042 and 0.036, respectively). The administration of acetazolamide, either isolated or in combination with prone positioning, not only could not significantly lower the complication rates, but also added the burden of side effects. CONCLUSIONS The current study demonstrates the possible role of prone positioning in mitigating the complication rates subsequent to untethering surgeries. Clinical trial registration no.: NCT01867268 ( clinicaltrials.gov ).

Spinal cord malformations

Malformations of the spinal cord are one of the most frequent malformations. They should be clearly divided into two completely different families of malformations: open dysraphisms and occult dysraphisms. Open dysraphism mostly consists in myelomeningocele (MMC). Its incidence is 1/1000 live births with a wide variation. Folic acid supplementation has been shown to reduce its risk. In most cases, the diagnosis is done prenatally by serum screening and ultrasound and may lead to termination of pregnancy. In case of decision to continue pregnancy, surgical treatment must be achieved during the first days of life, and in 50 to 90% of cases, a ventricular shunt must be installed. The follow-up of these children must be continued throughout life looking for late complications (Chiari II and syringomyelia, vertebral problems, neuropathic bladder, tethered cord). Occult dysraphisms are a heterogeneous group of malformations. Lipomas (filum and conus) are the most frequent and their treatment remains controversial. Diastematomyelia, neurenteric cysts, dermal sinus, and more complex forms (Currarino syndrome) belong to this group. Most of them can and must be diagnosed prenatally or at birth by careful examination of the lower back for the cutaneous stigmata of the disease to decrease the risk of neurological, urological, or orthopedic permanent handicap.

Management of multiple tethering in spinal dysraphism

INTRODUCTION

The most challenging component of spinal dysraphism is cord tethering. Tethering can occur due to single or multiple lesions within the same patient. It is imperative to aggressively identify and release all the tethering lesions in order to provide maximum benefit to the patient. With increasing number of tethering lesions, the clinical profile and outcome show significant differences, and this difference is significantly more when more than two tethering lesions coexist in the same patient.

MATERIAL AND METHODS

Out of the 248 patients of spinal dysraphism who underwent surgical management at Sanjay Gandhi Institute of Medical Sciences, Lucknow, India, between 1997 and 2007, 160 were included in the study. Patients were classified into two groups based on the number of tethering lesions. The first group (Group A) comprised cases of spinal dysraphism with tethering demonstrable at one or two sites. The second group (Group B) comprised patients with radiological or intraoperative evidence of multiple tethering lesions (more than two).

RESULTS

There were 119/160 patients in Group A, while 41/160 patients were in Group B (with more than two sites of tethering). The preoperative neurological examination revealed significant differences between the two study groups. The clinical profile and the surgical outcomes have shown significant differences in the two study groups. These differences are statistically significant.

CONCLUSION

We strongly believe that the mere presence or absence of tethering is not a sufficient documentation to predict its effect on the cases of spinal dysraphism. Tethering is a complex entity that needs to be further classified in terms of the number of tethering lesions, which significantly affect the pre- and postoperative status of the patients. We would like to suggest the term "Spina Bifida Multiplex" for the cases where more than two lesions are found to be responsible for tethering.

Anterior sacral pyocele with meningitis: a rare presentation of occult spinal dysraphism with congenital dermal sinus

The authors describe an interesting case of a hitherto asymptomatic occult spinal defect with a congenital sacral dermal sinus which proved to be the entry point for bacterial meningitis in an otherwise healthy 9-year-old female child. The patient presented with fever and neck stiffness, and a dermal sinus in the lumbosacral region was identified on examination. Cerebrospinal fluid analysis confirmed bacterial meningitis and a spinal magnetic resonance imaging scan revealed a dermal sinus tract with an anterior spinal meningocele, caudal regression syndrome, and a tethered spinal cord. In addition to administration of intravenous antimicrobial agents, surgical exploration of the sacral dermal sinus tract was performed and an anterior sacral pyocele was drained. The pyocele cavity was disconnected from the thecal sac, and the thickened and fatty filum terminale was sectioned. Although congenital sacral dermal sinus manifesting as bacterial meningitis is known, the occurrence of an anterior sacral pyocele has not yet been described in children.

Evaluation of clinico-urodynamic outcome of bladder dysfunction after surgery in children with spinal dysraphism - a prospective study

BACKGROUND

The aim was to asses the clinical profile and urodynamic findings and the outcome of surgery in children with spinal dysraphism.

METHOD

Twenty five children with spinal dysraphism who were treated at our institute between January 2005 and June 2006 were studied prospectively. There were 10 with an open spina bifida and 15 closed. The clinical profile of bladder dysfunction was assessed and urodynamic evaluation done pre-operatively in each child. An ultrasound study of the kidneys was also done to assess for hydro-uretero-nephrois. All underwent surgery for their primary and associated malformations. Post-operatively, re-evaluation of bladder dysfunction and urodynamic parameters was performed at 6-8 months.

RESULTS

Before operation there was a history indicating that the bladder was involved in 14 of the 25 children. Six of the 10 cases with an open spina bifida showed clinical involvement of the bladder as compared to 8 of 15 with a closed pattern. Urodynamic studies showed evidence of bladder dysfunction in 19 children. Of 10 with a meningomyelocele, there were abnormal urodynamics in 9 as compared to 10 of 15 with closed dysraphism. Follow up urodynamic studies showed improvement in 9 of 20 children 3 of 7 with a meningomyelocele and 6 of 13 with closed dysraphism.

CONCLUSION

Children with open spina bifida, as compared to closed dysraphism, tend to have more bladder dysfunction as exemplified on clinical history and urodynamic assessment. A pre-operative urodynamic study helps to identify severity of bladder dysfunction which is clinically overt cases and also identifies subtle bladder dysfunction in clinically silent cases. Evaluation after operation tends to shows better outcome in children with closed dysraphism. The study also identifies deterioration in some patients with seemingly clinical improvement.

Diastematomyelia in children: treatment outcome and natural history of associated syringomyelia

OBJECTIVE

To quantify the long-term outcome of children with diastematomyelia and the implication of syringomyelia in the natural history.

MATERIALS

Retrospective study of 17 children (nine girls and eight boys) with diastematomyelia operated during 1989-2004. Mean age at diagnosis was 3.4 years (range 5 days-12 years), mean follow-up was 5 years; 14 had excision of spur and cord untethering, 3 had excision of spur alone.

RESULTS

The bony spur was in the lumbar region in 12 and thoracic in 5 patients. Syringomyelia was present in eight (47%), associated with bony spur between L1 and 4 (p=0.088), spina bifida occulta in ten (58.8%), and spinal lipoma in one (6%). Preoperative Necker Enfants Malades (NEM) scores were 17 in eight patients, 16 in four, 15 in three, 13 in one, and 12 in one patient. Presenting neurological deficits were motor in eight, sensory deficits in three, and anal incontinence in one patient. There was improvement of NEM scores postoperatively in five patients only, but still with residual deficit. Repeat spur excision and cord untethering was performed in three patients for neurological deterioration 1-4 years after first operation. On postoperative MRI scans syringomyelia remained unchanged in all eight patients. There were one skin infection, one transient motor deterioration, and one patient with sensory deficit after surgery.

CONCLUSION

Prophylactic operations were associated with the best clinical outcome. Despite improvement, all patients with established preoperative deficit still had residual neurological deficits at their last follow-up. The associated syringomyelia remained unchanged after surgery, indicating that it does not contribute to the neurological syndrome.

A case of split cord malformation associated with myeloschisis

INTRODUCTION

Split cord malformation (SCM) associated with myeloschisis is a very rare form of spinal dysraphism. We encountered a case of SCM associated with myeloschisis showing split neural placodes (hemicords) in the upper lumbar region.

RESULTS

Radiological examinations, including prenatal MRI and postnatal CT scan, clearly demonstrated a bony spur between the two hemicords as well as myeloschisis, which facilitated a precise preoperative diagnosis of this complex anomaly. Resection of the spur, closure of the myeloschisis, and untethering of the thickened filum terminale were successfully accomplished in one stage. The presence of SCM associated with myeloschisis is consistent with the hypothesis of an ontogenic basis of neural development, and we emphasize the importance of early imaging including prenatal MRI for diagnosing this complex anomaly.

Outcome of meningomyelocele/lipomeningomyelocele in children of northern India

OBJECTIVE

To evaluate the clinical profile, associated anomalies and surgical outcome of children with meningomyelocele (MMC)/lipomeningomyelocele.

METHODS

Out of a total of 181 cases of spinal dysraphism treated at our Institute between 1996 and 2004, 102 (56.35%) cases of MMC/lipomeningomyelocele were analyzed retrospectively and prospectively. The clinical profile and radiological findings of these children were recorded. Craniospinal MRI was the essential investigation and was done as a management protocol at our Institute for these children. Eighty-two out of 102 (80.3%) cases had pure MMC/lipomeningomyelocele and 20/102 (19.6%) had associated split cord malformation (SCM; complex spina bifida). All these children underwent surgery for their primary and associated malformations as indicated. They were clinically assessed over a mean follow-up period of 3.6 years ranging from 1.5 months to 8 years. No urodynamic or evoked potential studies were done to assess the sphincteric outcome following surgery.

RESULTS

Forty-six (45.1%) of children with MMC had other associated tethering lesions, including the presence of SCM. Craniospinal axis screening remained an important tool to understand the associated tethering lesions and malformations. Only 58.8% of children had hydrocephalus; thus the incidence was much lower compared with reports from the western literature (80-96%). 63.3% of children with overt hydrocephalus required shunt surgery prior to the definitive surgery; however, 23.3% of cases required a shunt after the MMC has been closed. Improvement in clinical profile following microneurosurgery was observed in 42.8% of cases with motor involvement, 46.8% of cases with sensory dysfunction and 39.5% of cases with sphincteric involvement. Motor improvement was seen in 43.6% of cases of pure MMC/lipomeningomyelocele as compared to only 40.0% of cases of complex spina bifida. Sensory improvement was also better in pure MMC/lipomeningomyelocele group being seen in 48.0% of cases as compared to only 42.9% of cases of complex spina bifida.

CONCLUSION

Presence of SCM with MMC is referred to as complex spina bifida and is seen in a significant proportion (19.6%) of all cases of MMC. Thorough assessment of the craniospinal imaging needs to be done to look for the presence of multiple tethering lesions which could be present in the same case. Not all children with spinal dysraphism with hydrocephalus required shunt surgery or CSF diversion but a constant and vigilant follow up could avoid it in 13.3% of cases. Improvement in motor and sensory dysfunction was better in the pure MMC/lipomeningomyelocele group than in the complex spina bifida group. Improvement in sphincteric dysfunction, although seen in significant cases, was less compared with improvement in motor and sensory dysfunction. This probably represents a lack of definitive objective criteria for urodynamic improvement and a lack of proper rehabilitation. Electromyographic studies and uroflowmetry are required to asses the true sphincteric outcome following surgery.

Pattern and factors affecting management outcome of spina bifida cystica in Ile-Ife, Nigeria

BACKGROUND AND OBJECTIVE

There is paucity of data on the pattern and factors affecting the management outcome of patients with spina bifida cystica in the Ife-Ijesa zone, Nigeria. This study was designed to address this research question.

METHOD

One hundred and six consecutive cases of spina bifida cystica who presented in our hospital from January 1990 to December 2004 were reviewed. We obtained information on sociodemographic factors, medical history and management as well as clinical outcome. SPSS was used to analyze the data.

RESULT

Males constituted 54.7% and females 45.2% of cases. Mortality was high in those presented after the 4th week of life (p = 0.04). The malformation occurred in the lumbar and lumbosacral regions in 77.4%. Myelomeningocele was the most common type (86.8%). Hydrocephalus was recorded in 53.8% of patients. Surgical closure was done for 91.5% of the patients. About 77% of all the patients were discharged while 22.7% died. This was significantly related to age at presentation (p = 0.04) and infection before surgery (p = 0.045). Postoperative complications were more frequent in patients with ruptured lesions (p = 0.025), a larger size of defect (p = 0.028) and a lower birth weight (p = 0.006).

CONCLUSION

Myelomeningocele is the most common type of spina bifida cystica in our environment. Late presentation and preoperative infection are associated with high mortality in our patients.

An unusual presentation of lumbosacral dermal sinus with CSF leak and meningitis. A case report and review of the literature

Dermal sinus tracts are common skin manifestations seen with spinal dysraphism. Most of these dermal sinus tracts occur in the lumbosacral region. Though dermal sinus tracts are a common manifestation, their presentation with CSF leak is rare and important as they predispose to recurrent meningitis along with neurological deficits. Here we present an interesting case of a 33-month-old female child with dermal sinus CSF leak, tethered cord and intradural dermoid who presented with meningitis and was treated with excision of the tract, removal of the dermoid and detethering of the cord.