Outcome of untethering for symptomatic spina bifida occulta with lumbosacral spinal cord tethering in 31 patients: analysis of preoperative prognostic factors

A retrospective analysis of spinal teratomas and spinal lipomas: overlaps and differences in presentation, surgical treatments, and outcomes

BACKGROUND

Spinal teratomas and lipomas, both adult and pediatric cases, are rare diseases with many similarities, but have yet to be systematically compared.

PURPOSE

To systematically compare spinal teratomas and lipomas to optimize management.

STUDY DESIGN

Retrospective PATIENT SAMPLE: Symptomatic spinal teratoma and lipoma patients surgically treated at our center.

OUTCOME MEASURES

Anatomical distribution, clinical manifestations, resection status, and outcomes.

METHODS

Spinal teratoma and lipoma patients with complete data treated during 2008-2023 in our center were enrolled. Electrophysiological monitoring was routinely performed after 2012. Patient characteristics, anatomical distribution, clinical manifestations, surgical resection, and outcomes were analyzed.

RESULTS

We enrolled 86 teratoma patients (71 adults) and 51 lipoma patients (39 adults). Most tumors were lumbosacral lesions; cervical/thoracic involvement was more common with lipomas. Pain, the most frequent manifestation, was more common in teratomas. Gross total resection (GTR) was achieved in 51.1% and 49% of teratomas and lipomas, respectively. Electrophysiological monitoring increased the GTR rate from 38.8% to 48.6%. Age independently predicted (OR: 1.040, 95% CI: 1.008-1.078) GTR/near-total resection (NTR). Symptom relief occurred in 81.4% teratoma patients and 64.7% lipoma patients. Recurrence/symptomatic progression occurred in 19 teratomas and 7 lipomas after a median of 95 and 115 months, respectively. Adult lipoma patients without spinal dysraphism had lower recurrence rates. GTR (HR: 0.172, 95% CI: 0.02557-0.7028) and lesion length (HR: 1.351, 95% CI: 1.138-1.607) independently predicted recurrence/progression.

CONCLUSIONS

GTR should be pursued for adult/pediatric spinal teratomas and pediatric spinal lipomas. For adult spinal lipoma patients without dysraphism, conservative surgery could be considered.

Recurrent tethered cord: outcome and follow-up of 20 de-thetering for symptomatic spina bifida: choort study

OBJECTIVE

The objective of this study was to evaluate the prevalence of tethered cord among patients in the postoperative period of open and occult spina bifida. To identify warning signs for its early diagnosis, as well as outcomes after the new surgical approach.

METHODS

Retrospective study of patients followed at the Pediatric Neurosurgery Department of the Federal University of São Paulo with spinal dysraphism. Signs and symptoms indicating reoperation were collected, and postoperative results were classified as improved, unchanged, or worsened.

RESULTS

222 medical records of patients diagnosed with spinal dysraphism were evaluated. Symptomatic Tethered Cord Syndrome (STCS) was identified in 30 patients (13.51%), with clinical manifestations related to orthopedic deformities (66.7%), neurological deficits (56.7%), urological dysfunction (50%), and intestinal dysfunction (40%). 20 cases underwent surgery for tethered cord release. The mean age at the time of surgery was 7.7 ± 4.9 years, with 13 female patients (65%). In the postoperative evaluation, improvement in low back pain (90.9%), urological pattern, and urinary tract infection episodes (45.4%) were particularly noteworthy. 3 patients (33.3%) with constipation showed improvement, and one worsened (11.1%). Improvement in ambulation was seen in two cases (16.7%). Low back pain was the first symptom to improve after surgery, with an average time of 1.3 months, followed by changes in the urological pattern at 15.6 months. Improvement in constipation was observed in the first month in 2 cases (66.7%), positive changes in ambulation were observed around 7 months after surgery, and only one case showed improvement in clubfoot correction.

CONCLUSIONS

The prevalence of tethered cord recurrence after primary correction surgery for open or occult neural tube closure defects was similar to that found in the literature. The results were encouraging, with good postoperative evolution of patients, especially in the improvement of low back pain and urological symptoms.

Avoiding the antenatal counselling faux pas: bridging the gap between prenatal prognostication and postnatal outcome of closed spina bifida

PURPOSE

Closed spina bifida (CSB) is rare in prenatal literature, and various lesions are grouped under this broad nosological entity CSB, leading to confusing and misleading prognostic conclusions.

METHODS

This is a retrospective observational cohort study of prenatally detected CSB cases using two-dimensional ultrasound, complemented by three-dimensional ultrasonography and foetal MRI in indicated cases, from October 2014 to October 2021 in a tertiary-level single centre.

RESULTS

The most common upper vertebral level of CSB was lumbar in 66.6% (10/15). The sub-classification of lesions based on prenatal ultrasound showed an agreement in 53% of the cases. Sixty percent had associated abnormalities identified postnatally, the most common being anorectal malformation seen in 33.3%. On postnatal follow-up, 46.6% had bowel incontinence and bladder dysfunction, and 33.3% developed lower limb deformities.

CONCLUSIONS

All CSBs do not have a uniformly favourable prognosis. The prognosis of CSB depends on the pathological type, the presence of associated abnormalities and the management.

Survey on Untethering of the Spinal Cord and Urological Manifestations among Spina Bifida Patients in Malaysia

The incidence and severity of urinary tract infections (UTIs) due to spina bifida is poorly understood in Malaysia. Tethering of the spinal cord is a pathological fixation of the cord in the vertebral column that can result in neurogenic bladder dysfunction and other neurological problems. It occurs in patients with spina bifida, and the authors of this study sought to investigate the impact of untethering on the urological manifestations of children with a tethered cord, thereby consolidating a previously known understanding that untethering improves bladder and bowel function. Demographic and clinical data were collected via an online questionnaire and convenient sampling techniques were used. A total of 49 individuals affected by spina bifida participated in this study. UTIs were reported based on patients’ observation of cloudy and smelly urine (67%) as well as urine validation (60%). UTI is defined as the combination of symptoms and factoring in urine culture results that eventually affects the UTI diagnosis in spina bifida individuals irrespective of CISC status. Furthermore, 18% of the respondents reported being prescribed antibiotics even though they had no history of UTI. Therefore, indiscriminate prescription of antibiotics by healthcare workers further compounds the severity of future UTIs. Employing CISC (73%) including stringent usage of sterile catheters (71%) did not prevent patients from getting UTI. Overall, 33% of our respondents reported manageable control of UTI (0–35 years of age). All individuals below the age of 5 (100%, n = 14) were seen to have improved urologically after the untethering surgery under the guidance of the Malaysia NTD support group. Improvement was scored and observed using KUB (Kidneys, Ureters and Bladder) ultrasound surveillance before untethering and continued thereafter. Spina bifida individuals may procure healthy bladder and bowel continence for the rest of their lives provided that neurosurgical and urological treatments were sought soon after birth and continues into adulthood.

Preoperative Videourodynamic Study Is Helpful in Predicting Long-term Postoperative Voiding Function in Asymptomatic Patients With Closed Spinal Dysraphism

Purpose

Controversy exists regarding the role preoperative urodynamic study for asymptomatic closed spinal dysraphism as it has failed to reveal the benefit in surgical decision and expectation of urological outcomes. We explore the relationship between preoperative videourodynamic study and postoperative urological outcomes after toilet training completed, focusing on their capability of spontaneous voiding.

Methods

We retrospectively reviewed the data of 181 patients who underwent preventive spinal cord untethering and followed at least till the completion of toilet training. Before untethering, patients underwent preoperative videourodynamic study. Postoperative voiding function was evaluated in 3 phases: (1) till postoperative 6 months, (2) till the completion of toilet training, and (3) 2 years after toilet training. Changing distribution of emptying pattern at each period was described. Also, relevance to preoperative urodynamic parameters on spontaneous voiding and urinary continence after toilet training was assessed.

Results

Spinal lipoma and low lying conus were found in 145 (80%) and 128 patients (70.7%), respectively. Spontaneous voiding was found in 125 (69.1%), 164 (90.6%), and 162 patients (89.5%) at postoperative 6 months, till the toilet training, and 2 years after toilet training, respectively. Videourodynamics helped to clarify the presence of vesicourethral synergy. This was correlated with spontaneous voiding at postoperative 6 months and better urinary continence after 2 years of toilet training.

Conclusions

Eventual spontaneous voiding was achieved till toilet training in 90% patients following preventive untethering. Those showing preoperative vesicourethral synergy was associated with faster achievement of spontaneous voiding and better urinary continence when they enter elementary school.

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]

Clinical and urodynamic features of secondary tethered cord syndrome: How can they be found longitudinally?

PURPOSE

Secondary tethered cord syndrome (TCS) can be diagnosed with signs of progressive deterioration in urological or neuro-orthopedic systems following primary untethering surgery. Though urological deterioration is a common secondary TCS manifestation, a paucity of diagnostic criteria makes diagnoses challenging. A detailed description of urological deterioration may help diagnose secondary TCS. Thus, the clinical and urodynamic features of the current secondary TCS cases were described.

MATERIALS AND METHODS

Fifty-one patients who had undergone reuntethering for secondary TCS experienced improvement or stabilization of progressive problems. Moreover, their clinical and videourodynamic changes were longitudinally described.

RESULTS

Loss of postoperative spontaneous voiding was the first urological secondary TCS sign for those who could void spontaneously. Urological problems mostly occurred during elementary school (6-12 years). Major urological presentations were recalcitrant urinary tract infection or urinary incontinence. Follow-up videourodynamic studies revealed typical changes, from acontractile bladder to overactive and low-complaint bladders. While detrusor overactivity did not always occur during the progression, detrusor sphincter dyssynergia was always present in all patients with urological deterioration. All patients postoperatively showed significant urodynamic improvement regardless of preoperative bladder dysfunction. This included four cases of restoring spontaneous voiding. Nine patients experienced newly appearing nonprogressive neuro-orthopedic complications despite their urological improvement.

CONCLUSIONS

Urological deterioration should prompt secondary TCS suspicion, and changes in clinical patterns and videourodynamic studies helped diagnose it. However, reuntethering can effectively address urological problems at the cost of some neuro-orthopedic functions in some patients.

Perspectives on urological care in spina bifida patients

Spina bifida (SB) is a neurogenetic disorder with a complex etiology that involves genetic and environmental factors. SB can occur in two major forms of open SB or SB aperta and closed SB or SB occulta. Myelomeningocele (MMC), the most common neural tube defects (NTDs), occurs in approximately 1 in 1,000 births. Considering non-genetic factors, diminished folate status is the best-known factor influencing NTD risk. The methylenetetrahydrofolate reductase (MTHFR) gene has been implicated as a risk factor for NTDs. The primary disorder in the pathogenesis of MMC is failed neural tube closure in the embryonic spinal region. The clinical manifestation of SB depends on clinical type and severity. SB can be detected in the second trimester using ultrasound which will reveal specific cranial signs. The management of MMC traditionally involves surgery within 48 h of birth. Prenatal repair of MMC is recommended for fetuses who meet maternal and fetal Management of Myelomeningocele Study (MOMS) specified criteria. Urological manifestations of SB include urinary incontinence, urolithiasis, sexual dysfunction, renal dysfunction, and urinary tract infection. Renal failure is among the most severe complications of SB. The most important role of the urologist is the management of neurogenic bladder. Medical management with clean intermittent catheterization and anticholinergic treatment is generally considered the gold standard of therapy. However, when this therapy fails surgical reconstruction become the only remaining option. This review will summarize the pathogenesis, risk factors, genetic contribution, diagnostic test, and management of SB. Lastly, the urologic outcomes and therapies are reviewed.

Surgical outcomes of six bulldogs with spinal lumbosacral meningomyelocele or meningocele

OBJECTIVE

To report the surgical treatment and outcome of six bulldogs with spina bifida (SB) and meningocele (MC) or meningomyelocele (MMC).

STUDY DESIGN

Case series.

ANIMALS

Five French bulldogs and one English bulldog with MC or MMC.

METHODS

Medical records of dogs with spinal MC or MMC diagnosed by MRI at two institutions between 2013 and 2016 were reviewed for surgical treatment and outcomes.

RESULTS

Meningocele was diagnosed in two dogs, and MMC was diagnosed in four dogs. A lumbosacral dimple was noted in all dogs along with neurological deficits most commonly consisting of urinary and fecal incontinence (n = 6) and mild/moderate paraparesis (n = 3). Dorsal laminectomy was performed in all dogs to allow dissection of the meningeal sac to the vertebral column defect. In dogs with MMC, nerves were repositioned and protruded meninges were removed prior to suturing remaining meninges. Adhesions and filum terminale were resected in two dogs with suspected tethered cord syndrome. Urinary and fecal incontinence improved in two dogs and remained unchanged in four. Paraparesis improved in two dogs.

CONCLUSION

Surgical treatment resulted in partial improvement of the urinary and fecal incontinence (2/6 dogs) and paraparesis (2/3 dogs) or stable neurological condition (3/6 dogs), with only minor temporary complications.

CLINICAL SIGNIFICANCE

In the absence of published data comparing surgical and conservative treatment of puppies affected by SB and MC or MMC, early surgical treatment can be considered to prevent deterioration of neurological signs and, eventually, facilitate improvement of neurological signs.

Surgical treatment of tethered cord syndrome-comparing the results of surgeries with and without electrophysiological monitoring

PURPOSE

To compare the short- and long-term outcomes after surgical treatment of tethered cord syndrome with and without electrophysiological monitoring.

METHOD

We collected the preoperative data of 102 tethered cord surgeries of 91 patients. We compared the outcomes regarding the presence of intraoperative electrophysiology, the types of surgeries and the preoperative neurological condition. We also analysed the long-term outcomes in the cases of 69 patients.

RESULTS

We found that intraoperative electrophysiology can reduce the perioperative surgical risk significantly (from 9.4 to 2.9%, p < 0.001), and electrophysiology is also beneficial in avoiding long-term progression in 88.7% (p = 0.03341).

CONCLUSION

Tethered cord surgeries are safe and effective. With the use of intraoperative electrophysiology, the risk of postoperative worsening is as low as 2.9%, and long-term progression can be avoided in the majority of the patients.

Spinal Shortening for Recurrent Tethered Cord Syndrome via a Lateral Retropleural Approach: A Novel Operative Technique

Spine shortening via vertebral osteotomy (SSVO) for recurrent tethered cord syndrome (TCS) is a novel surgical technique that avoids the complication profile associated with revision detethering. While SSVO has previously been described via a posterior approach, we describe a lateral retropleural approach for SSVO in recurrent TCS in a 21-year-old female.

Our patient presented with progressive lower extremity weakness, bowel and bladder incontinence, and back pain in the setting of childhood repair of myelomeningocele and two previous detethering procedures. SSVO was offered to the patient as further detethering was deemed to have significant risk. A discectomy at T11-T12 via the lateral retropleural approach was performed, followed by a T12 partial corpectomy removing the vertebral body down to the inferior aspect of the T12 pedicle, followed by the removal of the ipsilateral pedicle. The T10, T11, L1, and L2 pedicle screws were then placed in the prone position and temporary rods were placed for temporary stability, followed by a laminectomy at T12 and a facetectomy for posterior element release. The remaining pedicle was removed, permanent rods were sequentially placed, and spinal column shortening was achieved by compression against the rods. Standing lateral radiographs demonstrated 19 millimeters (mm) of shortening after the intervention. The patient remained at her neurologic baseline postoperatively. At the six-month follow-up, the patient reported decreased lower extremity radicular pain and improved bowel and bladder function.

This operative report demonstrates that SSVO via a lateral retropleural approach is a viable treatment for the recurrence of TCS. The advantages of this minimally invasive approach compared to the posterior approach are direct access to the vertebral body and disc space, avoiding the need to operate around the spinal cord. Further studies are necessary to assess this minimally invasive approach to spinal shortening and to see if a complete minimally invasive approach is possible.

Results of the prophylactic surgery of lumbosacral lipomas 20 years of experience in the Paediatric Neurosurgery Department La Timone Enfants Hospital, Marseille, France

We conducted a retrospective study of children with lumbosacral lipomas treated in the Department of Pediatric Neurosurgery hospital Timone Enfants in the last 20 years. We selected patients with lipomas of the conus medullaris who underwent preventive surgery. 86 ,4 % of the patients remained asymptomatic during the follow-up. Worse results were observed in children older than one year old at surgery with transitional lipoma, with the conus medullaris was below L5 and when the resection had been partial. In view of the results, the authors recommend the preventive surgery before the first year of life under neurophysiologic monitoring in order to perform a total near-total resection with a neural plate reconstitution.

Six-month postoperative urodynamic score: a potential predictor of long-term bladder function after detethering surgery in patients with tethered cord syndrome

PURPOSE

We evaluated changes in urodynamic parameters of patients with tethered cord syndrome after detethering surgery and investigated factors predicting long-term urological outcome based on a previously described urodynamic scoring system.

MATERIALS AND METHODS

A total of 148 patients with tethered cord syndrome underwent detethering surgery at our hospital between January 2005 and March 2011. Of these patients 44 with preoperative and postoperative urodynamic data and a minimum followup of 2 years were included. Urodynamic score was composed of 4 parameters, with the sum ranging from 0 (favorable) to a maximum score of 17 (unfavorable).

RESULTS

Mean ± SD age at surgery was 38.0 ± 77.2 months and followup was 57.2 ± 20.6 months. Preoperative symptoms were present in 24 patients. Total urodynamic score at 6 months postoperatively was higher than preoperatively (mean ± SD 5.61 ± 2.71 vs 4.43 ± 3.56, p = 0.033) and remained at a similar value during followup (5.88 ± 3.89). The 6-month postoperative total urodynamic score was significantly lower in the 23 patients with favorable urological outcomes than in those with unfavorable outcomes (3.87 ± 2.02 vs 7.52 ± 1.99, p <0.001), whereas the preoperative urodynamic scores did not differ between these groups. The difference in urodynamic scores between favorable and unfavorable outcome groups became more prominent with time. By regression analysis the total urodynamic score at 6-month followup was a predictor of urological symptoms at last followup (OR 2.763, 95% CI 1.514-5.043, p = 0.001).

CONCLUSIONS

Six-month postoperative urodynamic scores accurately predicted the presence of urological symptoms on long-term followup and may be an important predictor of long-term urological outcomes after detethering surgery.

Lack of uniformity in the clinical assessment of children with lipomyelomeningocele: a review of the literature and recommendations for the future

OBJECTIVE

An objective clinical assessment tool whose accuracy and reproducibility can be validated is essential for the initial evaluation, selection for surgery and surveillance of children with lipomyelomeningocele (LMMC). The aim of this study was to analyse the large number of such tools presently in use and recommend an alternative that could lead to greater uniformity between different series and greater consistency in the assessment of individual patients.

METHODS

A systematic review of the literature between January 1980 and December 2010 was undertaken and details of how the children in each series were assessed and the degree to which age was taken into account recorded.

RESULTS

Thirty-six different assessment tools were used in 40 different publications. None was validated in all aspects. Objective measures were used most in urological assessments but rarely in other domains. Age-specific assessments were used in only 10 % of publications.

CONCLUSION

This study confirmed that the assessment tools for evaluation of children with LMMC are inconsistent, often vague and poorly validated. This compromises the ability of clinicians who care for them to compare studies across centres for both treated and untreated children. We have sought to highlight those criteria which are relevant, measurable and reproducible and which might be combined into an easily applied assessment.

Anomalies associated with anorectal malformations according to the Krickenbeck anatomic classification

PURPOSE

We evaluated the incidence of congenital anomalies associated with anorectal malformations (ARMs) in relation to the anatomic type of ARM as defined by the Krickenbeck classification.

METHODS

We reviewed 99 children with ARM in our institution from 2002 to 2011. Data were collected on patient demographics, type of ARM, and associated congenital anomalies, which were categorized according to organ systems. Statistical analysis was performed for comparison between groups using 'perineal fistula' as the base group.

RESULTS

There were 62 (63%) male patients. The majority had perineal fistulas (35, 35%). Seventy-seven (78%) had at least one associated malformation. The most frequent malformations seen were genitourinary (28, 28%) and spinal anomalies (26, 26%). Those with rectovesical fistula had the highest proportion of genitourinary malformations (Odds Ratio [OR], 41.3; 95% confidence interval [CI], 4.7-363.4). Those with cloaca (OR, 49.5; 95% CI, 3.4-718.9) and those with rectovestibular fistula (OR, 12.4; 95% CI, 2.3-65.6) were most likely to have major spinal abnormalities, with tethered cord seen in all groups. The rectovestibular group was also most likely to have other associated malformations (OR, 8.6; 95% CI, 2.2-32.8).

CONCLUSION

More than 75% of children with anorectal malformation have other associated malformations. Genitourinary anomalies are the most common. Major spinal anomalies are seen in all groups, affecting nearly half of those with rectovestibular fistula and those without fistula. The incidence of associated malformations in the rectovestibular group is higher than described in the literature. Thorough systematic evaluation of all infants with ARM should be done regardless of type of ARM.

One-stage major spine deformity correction surgery: comparison between groups with and without additional neurosurgical intervention, with more than 24 months of follow-up

Object

Early-onset, nonidiopathic spine deformities are frequently caused by intraspinal anomalies necessitating both neurosurgical and orthopedic intervention. The clinical tradition at most treatment units is to perform neurosurgical and orthopedic procedures separately. Sometimes the deformity correction surgery is also done in stages, which leads to several periods of hospitalization, increased use of health care resources, and a long rehabilitation time for the patient. The purpose of this project was to perform an outcome survey for major spine surgery in high-risk patients, and to analyze whether an additional neurosurgical intervention during the same session increased the risk of complications.

Methods

A consecutive series of 81 patients with major rigid spine deformities treated by the same orthopedic surgeon was analyzed. In 24 of 81 cases there were additional intraspinal pathological entities indicating a neurosurgical procedure. All cases were divided into 2 groups: one with anterior-posterior surgery and also neurosurgery, and the other with anterior-posterior surgery but without neurosurgery. The result variables for the group comparisons were as follows: clinical and radiographic outcome, operating time, length of intensive care and hospital stay, relative blood loss, and occurrence of complications or adverse events. Groups were similar in terms of sex, size of spinal curve, and surgical procedures, but different in terms of diagnosis (there were more patients with myelomeningocele in the group treated with both anterior-posterior surgery and neurosurgery) and patient age (the group with both anterior-posterior surgery and neurosurgery was younger).

Results

An additional neurosurgical procedure combined with fusion surgery did not increase the complication rate or use of resources compared with fusion surgery alone, except in the length of operating time. The mean correction of the spinal curve was 56.7%, and the mean correction of the pelvic obliquity was 74.7%. The loss of correction was 3° on average. A more than 10° progression was seen in 9 cases. There were no deaths, and there were no neurological complications or surgery-related deterioration of ambulatory function. There were 10 complications that altered the planned postoperative course, including 5 infections.

Conclusions

One-stage major spine surgery, even when neurosurgery is included, is safe and does not increase the risk of complications. The increase in hospital and ICU stays is marginal.