Multidisciplinary evaluation of occult spinal dysraphism in 47 children

Course of Urological Problems in Children with Spinal Dysraphism: Long-Term Follow-Up Results

BACKGROUND/AIMS

We aimed to evaluate the course of urinary problems in children with spinal dysraphism.

METHODS

This multicenter study evaluated data on pediatric patients diagnosed with spinal dysraphism between 2010 and 2019. The neurological and urological conditions of the patients were examined retrospectively. This study focused on the course of urological problems. Urodynamic examinations including urodynamic bladder capacity, bladder pressure in maximal capacity, compliance, detrusor hyperactivity, uroflowmetry, and residual urine amount were evaluated. All patients underwent urinary system ultrasonography, urinalysis, hemogram and biochemical tests, and urodynamics at admission and follow-ups.

RESULTS

A total 62 patients (35 males, 27 females) with a mean age of 7.50 ± 4.01 years and age range of 1-16 years were included in the study. Ultrasonographic evaluation revealed normal results in 32 patients and abnormal findings, including moderate-to-severe calyceal dilatation, parenchymal thinning, and residual urine, in 30 patients. At the time of diagnosis, culture-positive urinary tract infection was detected in 22 patients, and leukocyte and/or bacterial positivity was detected in 18 patients. The differences between bladder capacity, bladder pressure at maximal capacity, compliance, and detrusor hyperactivity at first admission and post-treatment were statistically significant (p < 0.05). Vesicoureteral reflux was also detected in 25 patients. Thirty patients underwent oral anticholinergic and antibiotic prophylaxis, while 17 additionally underwent clean intermittent catheterization. Five patients underwent intravesical Botox injection, clean intermittent catheterization, and medical treatment, and 10 patients underwent augmentation cystoplasty.

CONCLUSION

The prevalence of urinary tract problems is high in patients with spinal dysraphism for whom early diagnosis is very important for both urologic and neurosurgical considerations. Early follow-up of urodynamics should be performed, and treatment should be carried out if necessary. Regular follow-up and appropriate treatment have positive effects on the quality of life of these patients and may also prevent the occurrence of severe renal dysfunction.

Importance of Physical Examination and Imaging in the Detection of Tethered Cord Syndrome

Tethered cord syndrome (TCS) is a type of occult spinal dysraphism that may lead to permanent neurologic and orthopedic deficits. Infants with TCS may have lumbosacral cutaneous malformations (LsCMs). We studied 67 infants referred to a single pediatric urology practice for a urological concern unrelated to occult spinal dysraphism with no prior diagnosis of LsCM between March 1, 2015 and September 30, 2018. Each infant underwent a spinal ultrasound. If an abnormality was detected, they were referred to a pediatric neurosurgeon. The most common cutaneous manifestations were duplicated or bifurcated (46%) gluteal folds and gluteal asymmetry (16%). Fourteen (21%) of the 67 patients had an abnormal spinal ultrasound; 5 of the 14 infants underwent a lumbar magnetic resonance imaging. One infant had urodynamics studies and a tethered cord release. Pediatricians should be familiar with TCS and perform lumbar physical examinations for LsCMs suggestive of TCS to ensure prompt diagnosis and management and avoid potentially devastating complications.

Diagnostic yield of lumbosacral magnetic resonance imaging requested by paediatric urology consultations

OBJECTIVES

In the historical series, the diagnostic yield of lumbosacral magnetic resonance imaging to rule out occult spinal dysraphism (or occult myelodysplasia), requested by paediatric urology, ranged from 2% to 15%. The aim of this study was to define our cost-effectiveness in children with urinary symptoms and to define endpoints that increase the possibility of finding occult spinal dysraphism.

PATIENTS AND METHODS

A screening was conducted on patients with urinary dysfunction for whom an magnetic resonance imaging was requested by the paediatric urology clinic, for persistent symptoms after treatment, voiding dysfunction or other clinical or urodynamic findings. We analysed clinical (UTI, daytime leaks, enuresis, voiding dysfunction, urgency, renal ultrasonography, lumbosacral radiography, history of acute urine retention, skin stigma and myalgia) and urodynamic endpoints (hyperactivity or areflexia, voiding dysfunction, interrupted pattern, accommodation value and maximum flow). A univariate analysis was conducted with SPSS 20.0.

RESULTS

We analysed 21 patients during the period 2011-2015. The median age was 6 years (3-10). Three patients (14.3%) had occult spinal dysraphism: one spinal lipoma, one filum lipomatosus and one caudal regression syndrome with channel stenosis. The endpoints with statistically significant differences were the myalgias and the history of acute urine retention (66.7% vs. 5.6%, P=.04; OR= 34; 95%CI: 1.5-781 for both endpoints).

CONCLUSIONS

The diagnostic yield of magnetic resonance imaging requested for children with urinary dysfunctions without skin stigma or neuro-orthopaedic abnormalities is low, although nonnegligible. In this group, the patients with a history of acute urine retention and muscle pain (pain, «cramps») can experience a greater diagnostic yield or positive predictive value.

Ultrasonography and magnetic resonance imaging evaluation of pediatric spinal anomalies

CONTEXT

Spinal dysraphisms are congenital abnormalities of the spine due to imperfect fusion of midline mesenchymal, bony and neural structures. Imaging plays a vital role in their evaluation as significant portion of patients may present with concurrent anomalies that need to be corrected simultaneously to avoid repeat surgeries.

AIMS

The aims of the study were to evaluate Spinal dysraphisms using USG and MRI and to correlate imaging findings with operative findings in patients undergoing surgery.

SETTINGS AND DESIGN

Hospital based observational study conducted over a period of year.

MATERIALS AND METHODS

38 cases of both sexes and below 12 years of age with spinal dysraphism were studied. USG was performed in 29 cases where acoustic window was available for proper evaluation. MRI was performed in all cases. USG findings were compared with MRI findings and operative follow up was taken in 23 cases who underwent operative management.

STATISTICAL ANALYSIS USED

Results were analysed using percentage and arithmetic mean.

RESULTS

39.47 % cases were male and 60.53 % cases were female. Neonatal period was the most common presenting age group. Closed spinal dysraphism (63.16%) was more common than open (36.84%). 79.31% cases showed full agreement between spinal USG and MRI examinations and 6 out of 20.69% showed partial agreement. On operative correlation, USG findings were confirmatory in 91.30% cases and MRI findings were confirmatory in 100% cases.

CONCLUSIONS

USG can be used as the initial modality for evaluation of spinal dysraphism as well as for screening of suspected cases. MRI is indicated to confirm abnormal USG findings, which shows all concurrent abnormalities and also provides additional anatomical details relevant to surgical planning.

Association of amyotrophic lateral sclerosis and Behcet's disease: is there a relationship? A multi-national case series

Neurological involvement may be seen in 5-30% of the patients with Behcet's disease (BD). Occasionally, parenchymal neurological involvement in BD can present as a spinal cord syndrome. However, motor neuron disease-like presentation is extremely uncommon. Here we are reporting five patients (all male; median age, 38) fulfilling both International Study Group criteria for BD and El Escorial criteria for amyotrophic lateral sclerosis (ALS). These patients were identified by a questionnaire sent to the members of the Neuro-Behcet Study Group of the International Study Group for BD. Three out of five patients had only motor presentations. In two patients, sensory and urinary manifestations were present as well. Spinal cord MRIs were normal in all, and brain MRIs were normal in four patients; one patient had nonspecific white matter changes. Two patients passed away 1-3 years after diagnosis of ALS, and two patients were lost to follow-up 3 and 11 years after admission; one patient is still alive 3 years after onset. The patients that are presented here might represent a rare form of neurological involvement in BD as well as sole coincidence. Larger prospective series are needed to further answer this issue.

Neurogenic bladder: etiology and assessment

A review of the various causes of neurologic impairment to the lower urinary tract in children was the aim of this presentation. The emphasis was on diagnosis, pathophysiology, and treatment that strive to maintain as normal a function as possible in order to achieve eventual urinary continence and health of the upper urinary tract. The latest principles based on the most up to date evidence are promulgated but with an eye towards historical prospective. The reader should gain an adequate understanding of various disorders that comprise this condition and feel comfortable with proposing options for management when faced with the responsibility of caring for an affected child.

Pax1/E2a double-mutant mice develop non-lethal neural tube defects that resemble human malformations

Many mouse models exist for neural tube defects (NTDs), but only few of them are relevant for human patients that are born alive with spina bifida aperta. NTDs in humans show a complex inheritance, which most likely result from the involvement of a variety of predisposing genetic and environmental factors. Hints toward the identity of predisposing genetic factors for human NTDs could come from mouse studies on the development of the neural tube and spinal cord, as well as from studies on associated features of this type of diseases. Among such features is the observation that pregnancies affected by a neural tube defect frequently show changes in thymus morphology, and in both neonatal and maternal T-cell repertoire. The genes for E2a and Pax1 have both been implicated in not only paraxial mesodermal development, but also in that of the immune system. Moreover, Pax1 mutant mice have been shown to display NTDs in digenic mouse models. In the present study we have investigated the phenotype of E2a null mutant mice that are also heterozygous for the so-called undulated mutation in Pax1. Here we report that such double-mutant mice develop a non-lethal NTD that strongly resembles the classic human NTD: spina bifida aperta, associated with defects of the axial skeleton, immune system and urinary tract.

The continent bladder: indications and techniques for the continent catheterizable segment

PURPOSE OF REVIEW

Continent catheterizable segments are a substantial part of the urologist's armamentarium for providing bladder drainage. It is used for a myriad of indications, and there are multiple techniques currently used for its formation. Despite refinements in these techniques significant complications still occur, and there is continued advancement and ongoing investigation. This review examines the current status of the continent catheterizable segment with regard to indications for its use, techniques in its formation, discussion of complications, and ongoing and future directions in research.

RECENT FINDINGS

The continent catheterizable segment is indicated when it is not feasible to use the urethra for evacuation (e.g. bladder exstrophy, neurogenic bladder, radiation injury, and marked urethral dysfunction) or to facilitate catheterization. Compliance with catheterization and irrigation regimens is essential in patient selection. Multiple methods exist for its formation, either with or without the need for bladder augmentation. Although Mitrofanoff techniques with multiple applications predominate, "hemi" augments with efferent limbs also play a significant role. Stoma placement should be performed to best facilitate catheterization. Complications relating to catheterizable segments mainly pertain to continence, stenosis, and ability to catheterize, with more significant morbidity relating to the bladder augmentation. Ongoing research to develop more physiologic tissue substitutes and less invasive techniques may hopefully be superseded by prevention of the underlying lower urinary tract pathology.

SUMMARY

Catheterizable segments allow the patient to control bladder evacuation, and continue to be refined by ongoing investigations in terms of indication and technique, with attendent decreasing morbidity.