Minimally Invasive Tubular Tethered Cord Release in the Pediatric Population

Tethered cord syndrome in patients with myelomeningocele: Presentation of 3 cases, technical note on re-anchoring without dural opening

Background

Following myelomeningocele (MMC) repair, 10-30% of patients develop tethered cord syndrome (TCS). Surgical intervention is critical to reverse the stretching of the spinal cord. Here, we describe a technique for spinal cord untethering without dural opening in these patients.

Methods

Three patients underwent spinal cord untethering without dural opening. The surgical technique involved reopening the previous incision and dissecting the scar tissue attached to the dura. A Spongostan sponge was inserted, and lateral sutures were placed between the dural sac and the adjacent muscles. Clinical outcomes, imaging findings, and urodynamic results were evaluated postoperatively.

Results

The technique demonstrated positive outcomes in all three cases. Patients showed symptom improvement, better positioning of the spinal cord on imaging studies, and enhanced bladder function on urodynamic evaluations.

Conclusion

Spinal cord re-untethering without dural opening may be a viable surgical option for selected patients with MMC, offering favorable outcomes with reduced risk.

Diagnosis and Treatment of Tethered Spinal Cord: A Systematic Review

CONTEXT

Tethered cord syndrome is associated with motor and sensory deficits.

OBJECTIVE

Our objective was to summarize evidence regarding the diagnosis, prophylactic surgery, symptomatic treatment, and repeat surgery of tethered spinal cord in a systematic review (CRD42023461296).

DATA SOURCES AND STUDY SELECTION

We searched 13 databases, reference-mined reviews, and contacted authors to identify diagnostic accuracy studies and treatment studies published until March 2024.

DATA EXTRACTION

One reviewer abstracted data, and a content expert checked the data for accuracy. We assessed the risk of bias, strength of evidence (SoE), and applicability.

RESULTS

The evidence base includes 103 controlled studies, many with risk of bias and applicability concerns, and 355 case series providing additional clinical information. We found moderate SoE for MRI diagnosing tethered spinal cord, with medium to high diagnostic sensitivity and specificity. A small number of prophylactic surgery studies suggested motor function benefits and stability of neurologic status over time, but also complications such as surgical site infection (low SoE). A larger body of evidence documents treatments for symptomatic patients; studies revealed improvement in neurologic status after surgical detethering (low SoE), but also postoperative complications such as cerebrospinal fluid leakage (moderate SoE). A small body of evidence exists for retethering treatment (low or insufficient SoE for all outcomes).

LIMITATIONS

There was insufficient evidence for key outcomes (eg, over- or undertreatment, clinical impact of diagnostic modalities, ambulation, quality of life).

CONCLUSIONS

This comprehensive overview informs difficult clinical decisions that parents and their children with tethered spinal cords, as well as their health care providers, face.

Disparities in indications and outcomes reporting for pediatric tethered cord surgery: The need for a standardized outcome assessment tool

PURPOSE

Tethered cord syndrome (TCS) is characterized by abnormal attachment of the spinal cord neural elements to surrounding tissues. The most common symptoms include pain, motor or sensory dysfunction, and urologic deficits. Although TCS is common in children, there is a significant heterogeneity in outcomes reporting. We systematically reviewed surgical indications and postoperative outcomes to assess the need for a grading/classification system.

METHODS

PubMed and EMBASE searches identified pediatric TCS literature published between 1950 and 2023. Studies reporting surgical interventions, ≥ 6-month follow-up, and ≥ 5 patients were included.

RESULTS

Fifty-five studies representing 3798 patients were included. The most commonly reported non-urologic symptoms were nonspecific lower-extremity motor disturbances (36.4% of studies), lower-extremity/back pain (32.7%), nonspecific lower-extremity sensory disturbances (29.1%), gait abnormalities (29.1%), and nonspecific bowel dysfunction/fecal incontinence (25.5%). Urologic symptoms were most commonly reported as nonspecific complaints (40.0%). After detethering surgery, retethering was the most widely reported non-urologic outcome (40.0%), followed by other nonspecific findings: motor deficits (32.7%), lower-extremity/back/perianal pain (18.2%), gait/ambulation function (18.2%), sensory deficits (12.7%), and bowel deficits/fecal incontinence (12.7%). Commonly reported urologic outcomes included nonspecific bladder/urinary deficits (27.3%), bladder capacity (20.0%), bladder compliance (18.2%), urinary incontinence/enuresis/neurogenic bladder (18.2%), and nonspecific urodynamics/urodynamics score change (16.4%).

CONCLUSION

TCS surgical literature is highly variable regarding surgical indications and reporting of postsurgical outcomes. The lack of common data elements and consistent quantitative measures inhibits higher-level analysis. The development and validation of a standardized outcomes measurement tool-ideally encompassing both patient-reported outcome and objective measures-would significantly benefit future TCS research and surgical management.

Expanding the Horizons of Minimally Invasive Spine Surgery: Experience of the Destandau Technique for the Treatment of Multiple Spinal Diseases

OBJECTIVE

Minimally invasive spine surgery is rapidly gaining popularity because of its versatile nature. Traditionally, prolapsed disc has been the most common disease targeted using this technique. However, its usefulness for various other diseases has also been shown in studies. We present our experience of using this technique for various spinal diseases apart from prolapsed discs.

METHODS

This is a retrospective study in which patients operated on by a single surgeon from January 2019 to April 2023 were included. Cases that required conversion to open technique were excluded. Intraoperative findings and postoperative courses were obtained from patient records.

RESULTS

A total of 47 patients were included in the study, of whom 29 were male and 18 were female. The various diseases treated comprised intradural extramedullary (IDEM) tumors (n = 23), hypertrophied/ossified ligamentum flavum (n = 9), arachnoid cysts (n = 6), dermoid/epidermoid cysts (n = 4), detethering of cord (n = 3), and posterior cervical decompression for an ossified posterior longitudinal ligament (n = 2). The average duration of surgery was 2.1 ± 1.2 hours and the mean intraoperative blood loss was 138.4 ± 59.1 mL. The mean length of hospital stay was 2.3 ± 0.9 days. Two patients had superficial wound infection and none of the operated patients had cerebrospinal fluid leakage. Re-exploration was not required in any of the operated patients.

CONCLUSIONS

Minimally invasive techniques for dealing with multiple diseases involving the spine are as good as traditional open techniques, with some additional advantages of lesser tissue trauma, early return to work, and so on. However, one must overcome the steep learning curve before adopting them in day-to-day practice.

Clinical Significance of Terminal Syringomyelia and Accompanying Congenital Anomalies of Neurosurgical Interest in Adult and Pediatric Patients with Tethered Cord Syndrome

Magnetic resonance imaging (MRI) can be used to examine tethered cord syndrome (TCS) and terminal syringomyelia (TS). Additionally, there is increasing evidence of an association between congenital anomalies and TCS. We aimed to identify the clinical and radiological characteristics of syringomyelia and other anomalies in pediatric and adult patients with TCS. This study included 54 TCS patients (mean age, 17.37 ± 15.83 years; 31 females) admitted to our department between 2010 and 2019. The patients were divided into two age groups: pediatric (<18 years; 63%) and adult (>18 years). Clinical findings, direct vertebrae radiographs, lower extremity radiographs, and spinal/cranial MRI findings were used to evaluate all patients. Computed tomography (CT) was performed to reveal the structure of the septum in patients with Diastematomyelia. Cranial ultrasonography or CT was performed if the fontanel was open or closed, respectively, in pediatric hydrocephalus cases. Pelvic ultrasonography and urodynamic tests were performed to evaluate other comorbid anomalies and urinary system pathologies. A thick filum terminale (73.3%) and diastematomyelia (44.4%) were found to cause spinal tension. The most common accompanying pathology was syringomyelia (78%). The common symptoms were urinary incontinence and bowel problems (71%), scoliosis (68%), and progressive lower extremity weakness (64.4%). It is difficult to distinguish the exact cause of symptoms in patients with TCS and TS. Due to the greater occurrence of other congenital spinal anomalies accompanying TCS, both preoperative symptoms and clinical findings are more severe in the pediatric group than in the adult group, and postoperative results may be more negative.

Anesthesia for Innovative Pediatric Surgical Procedures

Over the past few decades, there have been many advances in pediatric surgery, some using new devices (eg, VEPTR, MAGEC rods) and others using less invasive approaches (eg, Nuss procedure, endoscopic cranial suture release, minimally invasive tethered cord release). Although many of these procedures were initially met with caution or skepticism, continued experience over the past few decades has shown that these procedures are safe and effective. This article reviews the anesthetic considerations for these conditions and procedures.

Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series

Background

Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur et al., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF.

Methods

A retrospective chart review of all patients who underwent an L4-5 LLIF between May 2016 and March 2019 was performed. Baseline demographics and clinical characteristics, such as body mass index (BMI), medical comorbidities, surgical history, tobacco status, operative time and blood loss, length of stay (LOS), and post-op complications were recorded.

Results

A total of 220 (58% female and 42% male) cases were reviewed. The most common presenting pathology was spondylolisthesis. The average age, BMI, operative time, blood loss, and LOS were 64.6 years, 29 kg/m², 214 min, 75 cc, and 2.5 days respectively. A review of post-operative neurologic deficits revealed 31.4% transient hip flexor weakness and 4.5% quadricep weakness on the approach side. At 3-week follow-up, 9.1% of patients experienced mild hip flexor weakness (4 or 4+/5), 0.9% reported mild quadricep weakness, and 9.5% reported anterior thigh dysesthesias; 93.2% of patients were discharged home and 2.3% were readmitted within the first 30 days post discharge. Female sex, higher BMI and longer operative time were associated with hip flexor weakness.

Conclusions

LLIF at L4-5 is a safe, feasible, and versatile approach to the lumbar spine with an acceptable approach-related sensory and motor neurologic complication rates.