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Kondo A, Kamihira O, Itoh T, Gotoh M, Kato K. A 31-year follow-up of those with occult spinal dysraphism, who underwent spinal cord untethering: Lower urinary tract function, skin stigmata, fertility, and work participation. Int J Urol 2024. [PMID: 38634346 DOI: 10.1111/iju.15467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/01/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES This study evaluated patients with occult spinal dysraphism who underwent spinal cord untethering. METHODS Twenty-four patients who visited us between 1983 and 2000 were followed-up for a mean duration of 31 years. We studied their lower urinary tract function, skin stigmata, fertility, and work participation. RESULTS Questionnaires sent in 2022 revealed that 5 patients had normal voiding (Group A) and 19 patients had abnormal voiding (Group B). Groups A and B underwent spinal cord untethering at a mean age of 5.7 and 13.0 years, respectively, showing a significant statistical difference (p = 0.036). After spinal cord untethering, the number of patients with detrusor normoactivity increased from 0 to 5, i.e., 3 of 6 with detrusor overactivity (50%), 1 of 2 not examined, and 1 of 5 not known. Patients with detrusor underactivity also increased from 11 to 19. Severity of incontinence in the International Consultation on Incontinence Questionnaire-Short Form resulted in a mean value of 2.4 in Group A, which was significantly superior to the mean value of 9.1 in Group B (p = 0.004). Fourteen patients (58.3%) were married and had 21 healthy children. A majority of patients have had full-time jobs. A variety of skin stigmata were present in the lumbosacral region, and changes in vesico-urethral configurations were observed during a video-urodynamic study. CONCLUSIONS Our study identified that the early timing of spinal cord untethering performed in neonates or infants and detrusor overactivity prior to untethering surgery are important factors in achieving normal bladder function.
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Affiliation(s)
- Atsuo Kondo
- Department of Urology, Atsuta Rehabilitation Hospital, Nagoya, Japan
| | - Osamu Kamihira
- Department of Urology, Komaki Municipal Hospital, Komaki, Japan
| | - Tomonori Itoh
- Department of Internal Medicine, Atsuta Rehabilitation Hospital, Nagoya, Japan
| | | | - Kumiko Kato
- Department of Female Urology, Meitetsu Hospital, Nagoya, Japan
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Jiao L, Wang S, Yang X, Ma JX, Zheng L, Wang H, Xiang LB, Yu HL, Chen Y. Current Global Research Trends of Tethered Cord Syndrome Surgery: A Scientometric and Visual Analysis. World Neurosurg 2024; 183:206-213. [PMID: 38143026 DOI: 10.1016/j.wneu.2023.12.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Since tethered cord syndrome (TCS) may lead to neurologic and motor dysfunction, surgeries often are applied to relieve the symptoms. The aim of the research was to explore the current global research trends of TCS surgery. METHODS In this article, articles on TCS surgery in the Web of Science Core Collection from 1980 to 2023 were searched. Research trends, countries, institutions, journals, authors, highly cited articles, and key words were analyzed using bibliometric methods. The literature co-citation network was mapped using VOSviewer, and research hotspots and trends were analyzed using CiteSpace. RESULTS A total of 432 publications were included. The number of publications and related research interest in the field of TCS surgery has increased globally year by year. The United States is the largest contributor (154 publications). The journal Childs Nervous System has the greatest number of publications (48 publications) and the most frequently cited journal is Neurosurgery (973 citations). In network visualization, the institution with the greatest contribution is University of California System (16 publications). Lee JY and Wang KC are the authors with the greatest number of publications (8 publications), and the most frequently cited author is Klekamp J (268 citations). Neurogenic bladder and spina bifida may be the next hot spot in this field. CONCLUSIONS This study will help researchers to identify the mainstream research directions and the latest hotspots in the field of TCS surgery and provide a reference for further research.
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Affiliation(s)
- Liang Jiao
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Shuang Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiao Yang
- Department of Anesthesiology, The Air Force Hospital of Northern Theater PLA, Shenyang, China
| | - Jun-Xiong Ma
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Liang Zheng
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Hong Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Liang-Bi Xiang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Hai-Long Yu
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Chen
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, China.
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Hara T, Ohara Y, Kondo A. Diagnosis and Management of Tethered Cord Syndrome. Adv Tech Stand Neurosurg 2024; 49:35-50. [PMID: 38700679 DOI: 10.1007/978-3-031-42398-7_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Tethered cord syndrome is a condition in which the spinal cord is tethered by pathological structures such as a tight filum terminale, intradural lipomas with or without a connecting extradural component, intradural fibrous adhesions, diastematomyelia, and neural placode adhesions following closure of a myelomeningocele.It usually occurs in childhood and adolescence as the spine grows in length, but it can also develop in adulthood. Symptoms of tethered cord syndrome are slowly progressive and varied. Incorrect diagnosis and inappropriate treatment may be provided if the physician lacks knowledge and understanding of this disease.This chapter aims to describe the pathophysiology, syndromes, diagnostic imaging, surgical treatment, and prognosis of tethered cord syndrome to enhance the understanding of this condition.
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Affiliation(s)
- Takeshi Hara
- Department of Neurosurgery, Spine and Spinal Cord Center, Juntendo University School of Medicine, Tokyo, Japan.
| | - Yukoh Ohara
- Department of Neurosurgery, Spine and Spinal Cord Center, Juntendo University School of Medicine, Tokyo, Japan
| | - Akihide Kondo
- Department of Neurosurgery, Spine and Spinal Cord Center, Juntendo University School of Medicine, Tokyo, Japan
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Jiao L, Yang X, Wang S, Ma JX, Zheng L, Wang H, Yu HL, Chen Y. Dekyphosis operation combined with limited osteotomy to treat the symptomatic adult tethered cord syndrome with complicated malformations: A case report. Medicine (Baltimore) 2023; 102:e33600. [PMID: 37115079 PMCID: PMC10145974 DOI: 10.1097/md.0000000000033600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
RATIONALE Tethered cord syndrome (TCS) represents a spectrum of neurological symptoms that are caused by constant or intermittent axial traction of the terminal cone of the spinal cord due to abnormal positioning. It is uncommon for abnormal structures of TCS to be accompanied by split cord malformation, thoracic spinal stenosis, and other spinal cord diseases. PATIENT CONCERNS A 45-year-old male patient visited our hospital due to severe lower back pain, extensive left lower limb muscle weakness, and intermittent claudication. DIAGNOSES TCS combined with stenosis of the thoracic canal, split cord malformation, and kyphosis deformity. INTERVENTIONS The patient underwent Dekyphosis operation combined with limited osteotomy symptoms. OUTCOMES The patient felt the right lower limb improved after surgery. At 4-month follow-up, a radiological examination showed adequate decompression of the spinal cord and a good internal fixation position. Overall, the patient's clinical symptoms significantly improved. CONCLUSION This is a rare case of TCS combined with thoracic disc herniation and bony mediastinum. A more conservative invasive surgical approach was elected and markedly improved the patient's symptoms. Additional clinical cases are needed to confirm the stability and feasibility of this surgical approach.
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Affiliation(s)
- Liang Jiao
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Xiao Yang
- Department of Anesthesiology, The Air Force Hospital of Northern Theater PLA, Dadong District, Shenyang, China
| | - Shuang Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Jun-Xiong Ma
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Liang Zheng
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Hong Wang
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Hai-Long Yu
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
| | - Yu Chen
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenhe District, Shenyang, China
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Oketani H, Harimaya K, Ono T, Terado K, Inoha S, Suzuki SO, Morioka T. A Presenile Patient with Filar Lipoma Who Developed Tethered Spinal Cord Syndrome Triggered by Lumbar Canal Stenosis. NMC Case Rep J 2023; 10:109-113. [PMID: 37197285 PMCID: PMC10185357 DOI: 10.2176/jns-nmc.2022-0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/09/2023] [Indexed: 05/19/2023] Open
Abstract
Lumbar canal stenosis (LCS) has been reported as a precipitating factor by which a tethered spinal cord, which is asymptomatic during childhood, develops into tethered cord syndrome (TCS) in adulthood. However, only a few reports on surgical strategies for such cases are available. A 64-year-old woman presented with unbearable pain in the left buttock and dorsal aspect of the thigh approximately 1 year ago. Magnetic resonance imaging showed cord tethering with a filar-type spinal lipoma and LCS due to the thickening of the ligamentum flavum at the L4-5 vertebral level. Five months after the decompressive laminectomy for the treatment of LCS, an untethering surgery was performed at the dural cul-de-sac at the S4 level. The severed end of the filum was elevated rostrally by 7 mm, and the pain subsided postoperatively. This case study shows that surgeries for both lesions should be indicated for adult-onset TCS triggered by LCS.
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Affiliation(s)
- Hiroshi Oketani
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Fukuoka, Japan
| | - Katsumi Harimaya
- Department of Orthopedic Surgery, Kyushu University Beppu Hospital, Beppu, Oita, Japan
| | - Teruaki Ono
- Department of Orthopedic Surgery, Kyushu University Beppu Hospital, Beppu, Oita, Japan
| | - Kazushige Terado
- Department of Orthopedic Surgery, Hachisuga Hospital, Munakata, Fukuoka, Japan
| | - Satoshi Inoha
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Fukuoka, Japan
| | - Satoshi O Suzuki
- Department of Psychiatry, Shourai Hospital, Karatsu, Saga, Japan
| | - Takato Morioka
- Department of Neurosurgery, Hachisuga Hospital, Munakata, Fukuoka, Japan
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Wang YT, Mu GZ, Sun HL. Thoracolumbar surgery for degenerative spine diseases complicated with tethered cord syndrome: A case report. World J Clin Cases 2022; 10:10375-10383. [PMID: 36246831 PMCID: PMC9561563 DOI: 10.12998/wjcc.v10.i28.10375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/21/2022] [Accepted: 08/24/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Tethered cord syndrome (TCS) secondary to split cord malformation (SCM) is rare in adulthood. There is as yet no consensus about the optimal treatment method for adult patients with SCMs and degenerative spine diseases such as lumbar stenosis, spondylolisthesis and ossification of the ligamentum flavum (OLF). The tethered cord poses a great challenge to the decompression and fusion procedures for the intraoperative stretching of the spinal cord, which might lead to deteriorated neural deficits. Here, we report on a case to add our treatment experience to the medical literature.
CASE SUMMARY We treated a 67-year-old female patient with type II SCM suffering from lumbar disc herniation, degenerative lumbar spondylolisthesis and thoracic OLF. The patient underwent thoracolumbar spinal fusion and decompression surgery for severe lower back pain, extensive left lower limb muscle weakness and intermittent claudication. After the thoracolumbar surgery, without stretching the tethered cord, the patient achieved complete relief of pain and lower extremity weakness at final follow-up.
CONCLUSION For adult patients with underlying TCS secondary to SCM coupled with thoracic OLF and lumbar spondylolisthesis, a thoracolumbar fusion surgery could be safe and effective with the tethered cord untreated. It is critical to design individualized surgical protocols to reduce the stretch of the low-lying spinal cord.
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Affiliation(s)
- Yue-Tian Wang
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
| | - Guan-Zhang Mu
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
| | - Hao-Lin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
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Klinge PM, Srivastava V, McElroy A, Leary OP, Ahmed Z, Donahue JE, Brinker T, De Vloo P, Gokaslan ZL. Diseased filum terminale as a cause of tethered cord syndrome in Ehlers Danlos syndrome: histopathology, biomechanics, clinical presentation, and outcome of filum excision. World Neurosurg 2022; 162:e492-e502. [DOI: 10.1016/j.wneu.2022.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
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Lei S, Hu Y, Wang M, Guo F. Filum Terminale Hemangioblastoma with Four Categories of Lesions. Ann Neurol 2021; 91:293-294. [PMID: 34786747 DOI: 10.1002/ana.26271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Shixiong Lei
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China.,International Joint Laboratory of Nervous System Malformations, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China
| | - Yan Hu
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China.,International Joint Laboratory of Nervous System Malformations, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China
| | - Meng Wang
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China.,International Joint Laboratory of Nervous System Malformations, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China
| | - Fuyou Guo
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China.,International Joint Laboratory of Nervous System Malformations, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan Province, China
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Congenital Tethered Cord Presenting as Chronic Back Pain in a 29-Yr-Old Woman. Am J Phys Med Rehabil 2021; 100:e162-e163. [PMID: 34673707 DOI: 10.1097/phm.0000000000001777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Theodore N, Cottrill E, Kalb S, Zygourakis C, Jiang B, Pennington Z, Lubelski D, Westbroek EM, Ahmed AK, Ehresman J, Sciubba DM, Witham TF, Turner JD, Groves M, Kakarla UK. Posterior Vertebral Column Subtraction Osteotomy for Recurrent Tethered Cord Syndrome: A Multicenter, Retrospective Analysis. Neurosurgery 2021; 88:637-647. [PMID: 33372221 PMCID: PMC7884146 DOI: 10.1093/neuros/nyaa491] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Few have explored the safety and efficacy of posterior vertebral column subtraction osteotomy (PVCSO) to treat tethered cord syndrome (TCS). OBJECTIVE To evaluate surgical outcomes after PVCSO in adults with TCS caused by lipomyelomeningocele, who had undergone a previous detethering procedure(s) that ultimately failed. METHODS This is a multicenter, retrospective analysis of a prospectively collected cohort. Patients were prospectively enrolled and treated with PVCSO at 2 institutions between January 1, 2011 and December 31, 2018. Inclusion criteria were age ≥18 yr, TCS caused by lipomyelomeningocele, previous detethering surgery, and recurrent symptom progression of less than 2-yr duration. All patients undergoing surgery with a 1-yr minimum follow-up were evaluated. RESULTS A total of 20 patients (mean age: 36 yr; sex: 15F/5M) met inclusion criteria and were evaluated. At follow-up (mean: 23.3 ± 7.4 mo), symptomatic improvement/resolution was seen in 93% of patients with leg pain, 84% in back pain, 80% in sensory abnormalities, 80% in motor deficits, 55% in bowel incontinence, and 50% in urinary incontinence. Oswestry Disability Index improved from a preoperative mean of 57.7 to 36.6 at last follow-up (P < .01). Mean spinal column height reduction was 23.4 ± 2.7 mm. Four complications occurred: intraoperative durotomy (no reoperation), wound infection, instrumentation failure requiring revision, and new sensory abnormality. CONCLUSION This is the largest study to date assessing the safety and efficacy of PVCSO in adults with TCS caused by lipomyelomeningocele and prior failed detethering. We found PVCSO to be an excellent extradural approach that may afford definitive treatment in this particularly challenging population.
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Affiliation(s)
- Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ethan Cottrill
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Corinna Zygourakis
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bowen Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zach Pennington
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erick M Westbroek
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - A Karim Ahmed
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeff Ehresman
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel M Sciubba
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy F Witham
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mari Groves
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Outcome in 32 cases of tethered cord in adults-is intervention justified? Childs Nerv Syst 2021; 37:195-202. [PMID: 32642975 DOI: 10.1007/s00381-020-04774-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Adults rarely present with tethered cord syndrome, and this review examines whether it is justifiable to perform surgical intervention in this group. METHODS Between 2003 and 2017, we performed surgical intervention in 32 adults with tethered cord syndrome. The age range varied from 22 to 65 years. Twenty-six had pain, 20 had motor deficits, and 18 had sensory deficits, whereas 17 presented with sphincter disturbances. Three had undergone surgery for meningomyelocele as infants. Six patients had major spinal deformity in the shape of kyphosis or scoliosis. All patients underwent digital radiographs and MR scans of the whole spine. The oldest with a leaking open meningocele was 41 years old. RESULTS The mean follow-up was 3.2 years. Twenty-one out of 26 patients presenting with pain had their VAS scores improve significantly; 14 had motor deficits which improved. However, sensory deficits got better in only 7 out of 18 patients, and sphincter improvement was documented (via urodynamics studies and bladder ultrasound) in only 4 out of 17 patients. In 15 cases, surgery was performed under neurophysiological monitoring, and overall improvement was documented in 11 of these patients compared with 7 of the remaining 17 patients. Surgery for spinal deformity was performed in 6 patients, and deformity correction as well as pain reduction was achieved in all. CONCLUSION Surgery leads to significant reduction of pain by untethering and in those with spinal deformity by correction of the same. Improvement in sensory changes and sphincter problems occurred in few patients. Neuromonitoring certainly has improved our results.
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Laurent D, Bardhi O, Gregory J, Yachnis A, Governale LS. Pediatric pathology all grown up - An interesting case of adult tethered spinal cord. Surg Neurol Int 2020; 11:362. [PMID: 33194295 PMCID: PMC7655999 DOI: 10.25259/sni_641_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/02/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Cervical myelopathy in an adult is typically the result of degenerative disease or trauma. Dysraphism is rarely the cause. Case Description: The authors report the case of a 35-year-old male drywall installer who presented with 2 years of progressive left upper extremity weakness, numbness, and hand clumsiness. Only upon detailed questioning did he mention that he had neck surgery just after birth, but he did not know what was done. He then also reported that he routinely shaved a patch of lower back hair, but denied bowel, bladder, or lower extremity dysfunction. Magnetic resonance imaging of the cervical spine demonstrated T2 hyperintensity at C4-C5 with dorsal projection of the neural elements into the subcutaneous tissues concerning for a retethered cervical myelomeningocele. Lumbar imaging revealed a diastematomyelia at L4. He underwent surgical intervention for detethering and repaired of the cervical myelomeningocele. Four months postoperatively, he had almost complete resolution of symptoms, and imaging showed a satisfactory detethering. The diastematomyelia remained asymptomatic and is being observed. Conclusion: Tethered cervical cord is a rare cause for myelopathy in the adult patient. In the symptomatic patient, surgical repair with detethering is indicated to prevent disease progression and often results in clinical improvement.
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Affiliation(s)
- Dimitri Laurent
- Department of Neurosurgery University of Florida, Gainesville, Florida, United States
| | - Olgert Bardhi
- Department of Neurosurgery University of Florida, Gainesville, Florida, United States
| | - Jason Gregory
- Department of Pathology, University of Florida, Gainesville, Florida, United States
| | - Anthony Yachnis
- Department of Pathology, University of Florida, Gainesville, Florida, United States
| | - Lance S Governale
- Department of Neurosurgery University of Florida, Gainesville, Florida, United States
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Xu F, Wang X, Li L, Guan J, Jian F. Tethered Cord Syndrome Caused by Duplicated Filum Terminale in an Adult with Split Cord Malformation. World Neurosurg 2020; 143:7-10. [PMID: 32711136 DOI: 10.1016/j.wneu.2020.07.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tethered cord syndrome (TCS) is a clinical diagnosis of progressive neurologic aggravation of the lower spinal cord due to a traction on the conus medullaris. Untethering surgery is effective for most TCS; however, when anatomic variations of spinal cord and filum terminale (FT) exist, regular untethering may lead to a failed outcome. CASE DESCRIPTION The authors present the case of a 45-year-old patient with TCS caused by duplicated FT with split cord malformation (SCM). Lumbosacral magnetic resonance imaging revealed a type II SCM with a significant low-lying conus medullaris. Laminectomy was performed. Neurophysiologic monitoring was used for nerve root identification and 2 thickened fila, which failed to respond on stimulation, were found during the surgery. Both fila were sectioned, and the diagnosis was finally confirmed by pathologic examination. Postoperatively, the patient's symptoms disappeared immediately and no neurologic sequela was found after surgery. CONCLUSIONS This is the first documented adult of duplicated FT with preoperative radiologic evidence and reported in association with SCM as a cause of TCS. When SCM exists, a careful observation for duplicated FT is warranted on preoperative magnetic resonance imaging and during surgery. Complete transection of the double FT under intraoperative neurophysiologic monitoring is the best treatment for this anomaly.
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Affiliation(s)
- Feifan Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China; Department of Neurosurgery, Peking University First Hospital, Beijing, P.R. China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China
| | - Liang Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, P.R. China
| | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China-INI, Beijing, P.R. China.
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14
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Abdallah A. Letter to the Editor Regarding “Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Metanalysis”. World Neurosurg 2020; 139:645-647. [DOI: 10.1016/j.wneu.2020.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 11/26/2022]
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Srinivasan ES, Mehta VA, Smith GC, Than KD, Terry AR. Klippel-Feil Syndrome with Cervical Diastematomyelia in an Adult with Extensive Cervicothoracic Fusions: Case Report and Review of the Literature. World Neurosurg 2020; 139:274-280. [PMID: 32339744 DOI: 10.1016/j.wneu.2020.04.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/27/2022]
Abstract
Split cord malformation (SCM) is a developmental disorder that is usually symptomatic and diagnosed in childhood. The majority of these lesions are in the thoracic and lumbar spine, with only 1%-3% of cases found in the cervical spine. This is a case report of a 55-year-old female patient with an unremarkable medical history who presented with neck pain. Upon workup, she was found to have extensive developmental anomalies throughout her cervical and thoracic spine, including an incidentally found type 2 SCM and multiple autofused vertebrae. There are only 6 similar studies published in the literature. There was extensive facet degeneration in her cervical spine, which was suspected to be the etiology of her neck pain. This case illustrates the rare finding of asymptomatic adult cervical SCM and the likely significance of her autofused vertebrae causing accelerated symptomatic facet spondylosis.
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Affiliation(s)
| | - Vikram A Mehta
- Duke University School of Medicine, Durham, North Carolina, U.S.A; Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, U.S.A..
| | - Gabriel C Smith
- Duke University School of Medicine, Durham, North Carolina, U.S.A; Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Khoi D Than
- Duke University School of Medicine, Durham, North Carolina, U.S.A; Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Anna R Terry
- Duke University School of Medicine, Durham, North Carolina, U.S.A; Division of Spine, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, U.S.A
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Breton JM, Yang MJ, Riesenburger RI. The use of decompressive segmental sublaminoplasty to treat myelopathy caused by lumbar stenosis in tethered cord syndrome. J Surg Case Rep 2020; 2020:rjaa041. [PMID: 32226600 PMCID: PMC7092679 DOI: 10.1093/jscr/rjaa041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 01/14/2020] [Accepted: 03/06/2020] [Indexed: 12/31/2022] Open
Abstract
A 79-year-old woman presented with acute-onset right leg pain in the setting of 3 months of progressive gait deterioration and bilateral leg weakness. On exam she had right lower extremity hyperreflexia and weakness. Lumbar spine magnetic resonance imaging demonstrated L3–L5 central canal stenosis with L4–L5 spondylolisthesis and a previously undiagnosed tethered cord. She underwent minimally invasive left segmental sublaminoplasty at L3–L4 and L4–L5 for spinal cord decompression with onlay arthrodesis resulting in resolution of her radicular pain and improved strength. This is a unique case of lumbar spinal stenosis presenting with myelopathy in the context of a previously asymptomatic and undiagnosed tethered cord.
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Affiliation(s)
| | - Michael J Yang
- Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
| | - Ron I Riesenburger
- Tufts University School of Medicine, Boston, MA, USA.,Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
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17
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Zhang C, Chang CC, Mummaneni PV, Yuan C, Dhall S, Jian F, Gupta N, Chou D. Spinal column shortening versus revision detethering for recurrent adult tethered cord syndrome: a preliminary comparison of perioperative and clinical outcomes. J Neurosurg Spine 2020; 32:958-964. [PMID: 32032960 DOI: 10.3171/2019.12.spine19659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recurrent 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. METHODS The 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. RESULTS Within 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. CONCLUSIONS Clinical 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.
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Affiliation(s)
- Can Zhang
- 1Department of Neurosurgery, University of California, San Francisco, California
- 2Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chih-Chang Chang
- 1Department of Neurosurgery, University of California, San Francisco, California
- 3Department of Neurosurgery, Taipei Veterans General Hospital, Taipei; and
- 4School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Praveen V Mummaneni
- 1Department of Neurosurgery, University of California, San Francisco, California
| | - Chenghua Yuan
- 2Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Sanjay Dhall
- 1Department of Neurosurgery, University of California, San Francisco, California
| | - Fengzeng Jian
- 2Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Nalin Gupta
- 1Department of Neurosurgery, University of California, San Francisco, California
| | - Dean Chou
- 1Department of Neurosurgery, University of California, San Francisco, California
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18
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O'Connor KP, Smitherman AD, Milton CK, Palejwala AH, Lu VM, Johnston SE, Homburg H, Zhao D, Martin MD. Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 137:e221-e241. [PMID: 32001403 DOI: 10.1016/j.wneu.2020.01.131] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/16/2020] [Accepted: 01/18/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In the healthy spine, the spinal cord moves unimpeded with spinal fluid pulsation in the rostral and caudal directions. When a portion of the spinal cord becomes attached to lesions within the spinal column, excess strain can cause signs and symptoms such as pain, motor deficits, sensory deficits, bladder dysfunction, and bowel dysfunction. This condition is termed tethered cord syndrome. There are no clear guidelines for offering surgical intervention, although there is a general consensus that worsening signs and symptoms increase the likelihood that patients will need surgery. METHODS In this article, we conduct a systematic review and meta-analysis for all available literature within the Ovid (MEDLINE), PubMed, and Google Scholar databases to evaluate common symptoms among patients with tethered cord and to examine how surgery affects symptoms. RESULTS Within the cohort of 730 patients, 708 (97%) were treated surgically by a detethering procedure. The most common preoperative sign or symptom was pain (81%), followed by motor deficits (63%), sensory deficits (61%), bladder dysfunction (56%), and bowel dysfunction (15%). One percent of patients had no deficit or symptom. Pain was the symptom that was most responsive to surgery, with 81% of patients reporting that their pain improved after detethering. CONCLUSIONS Tethered cord syndrome should be included in the differential diagnosis in patients presenting with back or leg pain, somatosensory symptoms of the lower extremities, muscular weakness, urodynamic dysfunction, or bowel dysfunction. After a definitive diagnosis is made, patients should be counseled about surgical detethering as an option.
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Affiliation(s)
- Kyle P O'Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Adam D Smitherman
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Camille K Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Ali H Palejwala
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Sarah E Johnston
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Hannah Homburg
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | - Michael D Martin
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Milano JB, Barcelos ACES, Onishi FJ, Daniel JW, Botelho RV, Dantas FR, Neto ER, de Freitas Bertolini E, Mudo ML, Brock RS, de Oliveira RS, Joaquim AF. The effect of filum terminale sectioning for Chiari 1 malformation treatment: systematic review. Neurol Sci 2019; 41:249-256. [DOI: 10.1007/s10072-019-04056-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/28/2019] [Indexed: 10/25/2022]
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20
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Oculo-Auriculo-Vertebral Dysplasia With Craniocervical Instability and Occult Tethered Cord Syndrome. An Addition to the Spectrum? First Case Report and Review of the Literature. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e805. [PMID: 31579884 PMCID: PMC6743983 DOI: 10.5435/jaaosglobal-d-17-00085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Oculo-auriculo-vertebral spectrum (OAVS) is an uncommon congenital disorder of abnormal development of the first and second pharyngeal arches. This spectrum is characterized by craniofacial microsomia, epibulbar dermoids, ear abnormalities, renal and cardiac defects, and a wide range of vertebral segmentation and formation disorders. Frequently, the cervicothoracic spine is involved. Only recently, the morbidity attributed to the spinal abnormalities has gained attention. Strategy and timing of spine surgery has become increasingly important in patients with OAVS. Here, we report a case of OAVS with characteristic vertebral cervical and thoracic involvement and its sequelae requiring multiple spinal procedures, further complexed by an unprecedented occult tethered cord syndrome, which was successfully treated by surgical detethering. In this context, the recent literature on spinal anomalies is reviewed.
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21
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D'Agostino EN, Calnan DR, Makler VI, Khan I, Kanter JH, Bauer DF. Type I split cord malformation and tethered cord syndrome in an adult patient: A case report and literature review. Surg Neurol Int 2019; 10:90. [PMID: 31528428 PMCID: PMC6744800 DOI: 10.25259/sni-66-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/04/2019] [Indexed: 11/14/2022] Open
Abstract
Background: In a split cord malformation (SCM), the spinal cord is divided longitudinally into two distinct hemicords that later rejoin. This can result in a tethered cord syndrome (TCS). Rarely, TCS secondary to SCM presents in adulthood. Here, we present an adult female with Type I SCM resulting in TCS and a review of literature. Case Description: A 57-year-old female with a history of spina bifida occulta presented with a 2-year history of worsening back and left leg pain, difficulty with ambulation, and intermittent urinary incontinence; she had not responded to conservative therapy. Magnetic resonance imaging (MRI) revealed a tethered cord secondary to lumbar type I SCM. The patient underwent an L1–S1 laminectomy for resection of the bony septum with cord detethering. At 2-month follow-up, the patient had improvement in her motor symptoms and less pain. In literature, 25 cases of adult-onset surgically managed SCM with TCS were identified (between 1936 and 2018). Patients averaged 37 years of age at the time of diagnosis, and 56% were female. Conclusion: TCS can present secondary to SCM in adulthood and is characterized predominantly by back and leg pain.
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Affiliation(s)
- Erin N D'Agostino
- Department of Neurosurgery, Geisel School of Medicine, Dartmouth College, Hanover, United States
| | - Daniel R Calnan
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - Vyacheslav I Makler
- Section of Neurology, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - Imad Khan
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - John H Kanter
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - David F Bauer
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
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22
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Walker CT, Godzik J, Kakarla UK, Turner JD, Whiting AC, Nakaji P. Human Amniotic Membrane for the Prevention of Intradural Spinal Cord Adhesions: Retrospective Review of its Novel Use in a Case Series of 14 Patients. Neurosurgery 2019; 83:989-996. [PMID: 29481675 DOI: 10.1093/neuros/nyx608] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 12/05/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Tethering after spinal surgery is caused by adhesions that arise from intradural tissue manipulation. Microsurgical detethering is the only treatment for symptomatic patients, but retethering occurs commonly and no treatment is widely available to prevent this complication. OBJECTIVE To apply human amniotic membrane (HAM) grafts, which are immune-privileged and known to possess antifibrogenic properties, in patients requiring microsurgical detethering. For this first-in-human use, we evaluated the safety and potential efficacy of these grafts for preventing retethering. METHODS We retrospectively reviewed the medical records of all patients who required detethering surgery and received an HAM graft between 2013 and 2016 at our institution after various previous intradural spinal surgeries. In all 14 cases, intradural lysis of adhesions was achieved, an HAM graft was sewn in place intradurally, and a dural patch was closed in a watertight fashion over the graft. RESULTS Fourteen patients had received HAM grafts to prevent retethering. All patients had at least 6 mo of follow-up (mean follow-up, 14 mo). Retethering was noted in only 1 patient. Surgical re-exploration showed that the retethering occurred caudal to the edge of the HAM graft, with no tethering underneath the original graft. No complications were attributed specifically to the HAM graft placement. CONCLUSION This first-in-human series provides evidence that HAM grafts are a safe and potentially efficacious method for preventing retethering after microsurgical intradural lysis of adhesions. These results lay the groundwork for further prospective controlled trials in patients with this difficult-to-treat pathology.
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Affiliation(s)
- Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Alexander C Whiting
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Wang H, Li X, Wang Y, Sun J, Wang Y, Xu X, Zhang B, Shi J. Assessing Spinal Cord Injury Area in Patients with Tethered Cord Syndrome by Diffusion Tensor Imaging. World Neurosurg 2019; 127:e542-e547. [DOI: 10.1016/j.wneu.2019.03.195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022]
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Surgical treatment of tethered cord syndrome-comparing the results of surgeries with and without electrophysiological monitoring. Childs Nerv Syst 2019; 35:979-984. [PMID: 30963241 DOI: 10.1007/s00381-019-04129-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
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.
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Wang H, Sun J, Wang Y, Sun K, Xu X, Zhang B, Shi J. Homogeneous Spinal-Shortening Axial Decompression for Tethered Cord Syndrome: Modified Spinal Column Shortening. World Neurosurg 2019; 127:e517-e522. [PMID: 30928585 DOI: 10.1016/j.wneu.2019.03.192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Tethered cord syndrome is a rare and intractable disease. The aim of this study was to investigate surgical outcome of homogeneous spinal-shortening axial decompression (HSAD) for tethered cord syndrome through a minimum 3-year follow-up. METHODS Patients who underwent HSAD for tethered cord syndrome in our institution between May 2011 and July 2015 were included in this study. After a minimum 3-year follow-up, radiologic and clinical data were collected. Surgical outcome was evaluated with Japanese Orthopaedic Association, visual analog scale, International Consultation on Incontinence Questionnaire-Short Form, and Rintala scores and urodynamics. RESULTS The study included 64 patients (28 men and 36 women) with a mean age of 35.7 ± 18.1 years. Significant improvement of visual analog scale and Japanese Orthopaedic Association scores was noted postoperatively and at a minimum 3-year follow-up. At the final follow-up, Japanese Orthopaedic Association and visual analog scale scores in all patients were improved compared with preoperatively. The International Consultation on Incontinence Questionnaire-Short Form score was decreased from 14.94 ± 4.15 preoperatively to 7.63 ± 4.40 at final follow-up (P < 0.01). Rintala score was improved from 5.26 ± 3.45 preoperatively to 12.32 ± 3.43 at final follow-up (P < 0.01). All urodynamic parameters improved compared with preoperatively. CONCLUSIONS HSAD was effective and safe. The results were satisfactory with a minimum 3-year follow-up. HSAD could be an alternative surgical treatment of TCS.
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Affiliation(s)
- Haibo Wang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jingchuan Sun
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Wang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Kaiqiang Sun
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Ximing Xu
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Bin Zhang
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Jiangang Shi
- Department of Orthopedic Surgery, Spine Center, Changzheng Hospital, Second Military Medical University, Shanghai, China.
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26
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Novik Y, Vassiliev D, Tomycz ND. Spinal Cord Stimulation in Adult Tethered Cord Syndrome: Case Report and Review of the Literature. World Neurosurg 2019; 122:278-281. [DOI: 10.1016/j.wneu.2018.10.215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
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Elmesallamy W, AbdAlwanis A, Mohamed S. Tethered cord syndrome: surgical outcome of 43 cases and review of literatures. EGYPTIAN JOURNAL OF NEUROSURGERY 2019. [DOI: 10.1186/s41984-019-0029-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gubian A, Rosahl SK. Secondary sacral tethered cord syndrome after treatment of secondary cervical syringomyelia. J Clin Neurosci 2018; 61:285-289. [PMID: 30470654 DOI: 10.1016/j.jocn.2018.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 10/06/2018] [Accepted: 11/04/2018] [Indexed: 10/27/2022]
Abstract
A female patient operated at the age of 11 on a pilocytic astrocytoma in the posterior fossa, was re-operated for a recurrence 9 years later. A Torkildsen drain was placed in the 4th ventricle and she remained asymptomatic for 15 years before presenting again with acute hydrocephalus, tonsillar herniation, and a massive cervicothoracic syrinx. The symptoms retreated following craniocervical untethering and decompression. Two weeks later, however, she suffered from debilitating radiculopathy provoked by tethering of the cauda equina. Again, symptoms retreated completely after microsurgical intervention. This combination of a secondary Chiari-like malformation with cervical syringomyelia and tethering of the cauda equina in a single patient as a delayed complication of posterior fossa surgery has not been reported before. Diagnosis and treatment of lower tethered cord syndrome may be obscured and delayed in complex clinical situations. In particular, awareness to symptoms that are not related to syringomyelia is important in patients with a known syrinx and a history of posterior fossa surgery.
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Affiliation(s)
- Arthur Gubian
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
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Surgical management of adult type 1 split cord malformation. Report of two cases with literature review. J Clin Neurosci 2018; 52:119-121. [DOI: 10.1016/j.jocn.2018.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/08/2018] [Accepted: 03/05/2018] [Indexed: 11/18/2022]
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30
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Shukla M, Sardhara J, Sahu RN, Sharma P, Behari S, Jaiswal AK, Srivastava AK, Mehrotra A, Das KK, Bhaisora KS. Adult Versus Pediatric Tethered Cord Syndrome: Clinicoradiological Differences and its Management. Asian J Neurosurg 2018; 13:264-270. [PMID: 29682019 PMCID: PMC5898090 DOI: 10.4103/1793-5482.228566] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Dysraphic lesions in adults, presenting clinically as tethered cord syndrome (TCS), are relatively rare, and their optimal management remains controversial. Patients and Methods We performed a retrospective analysis of our pediatric database over a period of last 7 years to focus on the adult TCS. Our aim was to determine the clinicoradiological and etiopathological differences between adult and pediatric patients as well as to determine the results of surgery in adult TCS. Results Adult spinal dysraphisms constituted 15.4% of our patients (20 out of 130). Motor weakness, sphincteric dysfunction, and backache (n = 13, 65.0% each) predominated in adults unlike children who presented with subcutaneous swellings (n = 74, 67.6%) followed by motor weakness (n = 40, 46.4%), backache being reported by only three patients. The different pathologic substrates underlying adult dysraphisms were lipomeningocele (n = 8), split cord malformation (total = 7; Type 1: n = 5; Type 2: n = 2), dermal sinus (n = 2), and fatty filum (n = 3). On the other hand, meningomyelocele/meningocele (61, 54.9%) followed by split cord malformation Type 1 and 2 (n = 29, 26.1%) predominated in children. The radiological differences between the two groups were a higher incidence of vertebral body defects (hemivertebrae and butterfly vertebrae) and lack of intracranial anomalies in adults. At a mean follow-up of 20.5 months, the most common symptoms to improve following detethering were pain (11 out of 13, 84.6%) followed by motor weakness (six out of 13, 56.2%) and sphincteric control (7 out of 13, 53.8%). Conclusion Most common symptoms to improve following detethering in adult TCS were pain followed by motor weakness. The major radiological differences between these two groups were a higher incidence of vertebral body defects (hemivertebrae and butterfly vertebrae) and lack of intracranial anomalies in adults.
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Affiliation(s)
- Mukesh Shukla
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Pradeep Sharma
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadesh Kumar Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh Singh Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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31
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Clinical Outcomes of Primary and Revision Untethering Surgery in Patients with Tethered Cord Syndrome and Spinal Bifida. World Neurosurg 2018; 116:e66-e70. [PMID: 29649647 DOI: 10.1016/j.wneu.2018.03.221] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tethered cord syndrome (TCS) is an increasingly recognized clinical condition, with untethering surgery considered the classically effective treatment. Yet, as evidence has aggregated, the surgical outcomes of untethering remain controversial. This study aimed to systematically evaluate the clinical outcomes in patients who underwent primary or revision untethering. METHODS This retrospective study was conducted at the Department of Spine Surgery of Changzheng Hospital between January and December 2016. Patients with TCS who underwent untethering surgery were recruited for the study. Information collected included demographic data, main clinical manifestations, and outcomes after untethering surgery. RESULTS A total of 112 patients (60 males and 52 females) were included in this study, with mean follow-up of 13.7 years. The surgical outcomes of the primary untethering varied among symptoms, with remission rates of 30.0% for pain, 24.4% for paresthesia, 18.6% for motor deficit, 12.6% for bladder dysfunction, and 21.2% for bowel dysfunction. Moreover, 23.3%-40.2% of patients suffered deterioration after surgery during the follow-up period. Twenty-eight patients underwent revision untethering surgery. In these patients, the remission rate decreased by 5.6%-16.7% compared with the primary operation. Moreover, most patients (58.8%-70.6%) experienced no benefits after revision surgery. CONCLUSIONS With a possible high risk of recurrence, further exploration of the indications and timing of the untethering surgery is needed. Conservative treatment and omnidirectional care might be a better choice for patients with retethering with recurrent symptoms.
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Lan ZG, Richard SA, Lei C, Huang S. Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child: A case report and literature review. Medicine (Baltimore) 2018; 97:e0489. [PMID: 29668630 PMCID: PMC5916695 DOI: 10.1097/md.0000000000010489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder. PATIENT CONCERNS A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night. DIAGNOSES Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis. INTERVENTIONS He was operated on successfully and the cervical lordosis and pain resolved. OUTCOMES The child recovered well with no tumor recurrence and massive improvement of his life. LESSONS The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.
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Affiliation(s)
- Zhi Gang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
- Department of Immunology, Jiangsu University, Zhenjiang, Jiangsu, P.R. China
- Department of Surgery, Volta Regional Hospital, Ghana-West Africa
| | - Chuanfen Lei
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Siqing Huang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu
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Bai SC, Tao BZ, Wang LK, Yu XG, Xu BN, Shang AJ. Aggressive Resection of Congenital Lumbosacral Lipomas in Adults: Indications, Techniques, and Outcomes in 122 Patients. World Neurosurg 2018; 112:e331-e341. [PMID: 29337168 DOI: 10.1016/j.wneu.2018.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The authors reviewed the treatment of adult patients with congenital intraspinal lipomas with total/near-total resection and discussed their preoperative characteristics, prognostic factors, and surgical outcomes. METHODS Medical records of 122 adult patients with congenital lumbosacral lipomas undergoing total/near-total resection were systematically analyzed. The cohort was subdivided into 3 groups depending on symptom onset age: group 1 (≤5 years, n = 40), group 2 (>5 years but <18 years, n = 33), and group 3 (>18 years, n = 49). Preoperative and postoperative neurologic status were compared between groups and analyzed as a whole. RESULTS The most common symptom was bladder dysfunction (82.0%), followed by constipation (76.2%). At the 3-month follow-up, improvement was noted in most patients presenting with pain (87.2%) and neuropathic ulcers (70.0%). Overall, neurologic status was improved in 73.0% of patients and stabilized in 19.7% of patients. A binary logistic regression model identified shorter preoperative duration (P = 0.013) and preoperative pain (P = 0.005) as independent predictors of postoperative improvement. Neurosurgical complications developed in 16 patients, and wound complications occurred in 2 patients. Two of 3 patients who had recurred symptoms underwent repeated detethering surgery during long-term follow-up. CONCLUSIONS Despite longer preoperative duration than the pediatric population, adult patients with lumbosacral lipomas can still benefit from total/near-total resection especially regarding pain and foot ulcers, with low surgery-related morbidity. The long-term advantage of resecting additional lipoma in adults remains a point of discussion.
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Affiliation(s)
- Shao Cong Bai
- Department of Neurosurgery, PLA General Hospital, Haidian District, Beijing, China
| | - Ben Zhang Tao
- Department of Neurosurgery, PLA General Hospital, Haidian District, Beijing, China
| | - Le Kai Wang
- Department of Neurosurgery, PLA General Hospital, Haidian District, Beijing, China
| | - Xin Guang Yu
- Department of Neurosurgery, PLA General Hospital, Haidian District, Beijing, China
| | - Bai Nan Xu
- Department of Neurosurgery, PLA General Hospital, Haidian District, Beijing, China.
| | - Ai Jia Shang
- Department of Neurosurgery, PLA General Hospital, Haidian District, Beijing, China.
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Stamates MM, Frim DM, Yang CW, Katzman GL, Ali S. Magnetic resonance imaging in the prone position and the diagnosis of tethered spinal cord. J Neurosurg Pediatr 2018; 21:4-10. [PMID: 29076793 DOI: 10.3171/2017.3.peds16596] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tethered cord syndrome (TCS) is a neurosurgical disorder with varied clinical manifestations believed to result from vascular compromise due to stretch forces on the spinal cord. Conventional supine MRI findings may include a low-lying conus medullaris, thickened or fat-infiltrated filum terminale, or lipoma; however, imaging sensitivity and specificity for tethered cord can be low. The purpose of this study was to evaluate the utility of prone MRI in the diagnosis of tethered and retethered spinal cord. METHODS Medical records were reviewed in 41 patients who underwent surgical release of tethered cord and in whom preoperative prone MRI sequences were available. Patients were divided into Group 1 (new TCS diagnosis) and Group 2 (recurrent TCS after previous untethering). Absolute conus ventral motion and motion as a percentage of canal width between supine and prone positions was measured in these 2 groups via sagittal T2-weighted sequences; these groups were compared with 30 consecutive patients (Group 3) who were classified as the normal control group. RESULTS The mean ventral motion was as follows: Group 1 (absolute: 0.5 ± 0.5 mm [range 0-2.4 mm]; canal percentage: 3.7% ± 3.9% [range 0%-16.3%]); Group 2 (absolute: 0.4 ± 0.7 mm [range 0-2.6 mm]; canal percentage: 2.2% ± 3.7% [range 0%-14.0%]); and Group 3 (absolute: 3.4 ± 1.3 mm [range 1.4-5.6 mm]; canal percentage: 22.0% ± 7.2% [range 10.5%-36.1%]). Whereas 38/41 surgically treated patients with TCS had diminished (< 10% canal width) ventral motion on preoperative MRI, 30/30 controls had > 10% canal width motion. Sensitivity and specificity were thereby calculated as 92.7% and 100%, respectively. CONCLUSIONS In the present series, prone imaging is found to be a sensitive and specific tool, and the authors believe it may have a role as supportive evidence in the diagnosis of tethered and retethered spinal cord.
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Affiliation(s)
| | | | - Carina W Yang
- 2Department of Radiology, The University of Chicago, Illinois
| | | | - Saad Ali
- 2Department of Radiology, The University of Chicago, Illinois
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Steinberg JA, Wali AR, Martin J, Santiago-Dieppa DR, Gonda D, Taylor W. Spinal Shortening for Recurrent Tethered Cord Syndrome via a Lateral Retropleural Approach: A Novel Operative Technique. Cureus 2017; 9:e1632. [PMID: 29104840 PMCID: PMC5663326 DOI: 10.7759/cureus.1632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
| | - Arvin R Wali
- Department of Neurosurgery, University of California, San Diego
| | - Joel Martin
- Department of Neurosurgery, University of California, San Diego
| | | | - David Gonda
- Department of Neurosurgery, University of California, San Diego
| | - William Taylor
- Department of Neurosurgery, University of California, San Diego
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Starnoni D, Duff JM, Chittur Viswanathan G. Duplicated filum terminale in non-split cord malformations: An underrecognized cause for treatment failure in tethered cord syndrome. J Spinal Cord Med 2017; 40:481-484. [PMID: 27735228 PMCID: PMC5537966 DOI: 10.1080/10790268.2016.1227896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
CONTEXT Anatomical variations of the filum terminale (FT) have been described in association with split cord malformations (SCM) but they appear to be a rare finding in its absence. We report the first case in literature of a duplicated FT in a patient presenting with tethered cord syndrome (TCS) without any radiological evidence of SCM. FINDINGS A 47-year-old man presented with invalidating back pain radiating to both legs. Magnetic resonance imaging revealed an intradural dorsal lipoma in a low-lying conus. Intraoperatively two distinct fibrous bands were anatomically and electrophysiologically identified as the FT and both were sectioned. The diagnosis of FT was confirmed for both specimens by histology. CONCLUSION In absence of SCM, a duplicated FT has not been previously described as a cause of TCS. It may be a cause of treatment failure for TCS if unrecognized on preoperative imaging and during surgery if one filum remains intact. We highlight the importance of a meticulous cauda equina dissection supported by intraoperative nerve stimulation to identify this rare anomaly. We hypothesize that this entity may represent a variant of SCM involving the caudal neural tube but which requires further validation at an embryological level.
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Affiliation(s)
- Daniele Starnoni
- Neurosurgical Service, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John Michael Duff
- Neurosurgical Service, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Gopalakrishnan Chittur Viswanathan
- Neurosurgical Service, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland,Corresponding to: Gopalakrishnan Chittur Viswanathan, Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46 CH-1011, Lausanne, Switzerland.
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Abdallah A, Emel E, Abdallah BG, Asiltürk M, Sofuoğlu ÖE. Factors affecting the surgical outcomes of tethered cord syndrome in adults: a retrospective study. Neurosurg Rev 2017; 41:229-239. [DOI: 10.1007/s10143-017-0842-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 01/06/2017] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
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Satyarthee GD, Kumar A, Moscote-Salazar LR. Conus medullaris dermoid tumour. Uncommon presentation of conus medullaris dermoid as an exophytic mass lesion. ROMANIAN NEUROSURGERY 2017. [DOI: 10.1515/romneu-2017-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Authors report an extremely uncommon case dorsally exophytic conus dermoid in a three-years old boy, who underwent meningocele repair locate at lumbosacral region at an age of one month. The boy presented with low backache and difficulty in passing urine. Magnetic resonance imaging evaluation of spine revealed presence of a large exophytic mass located dorsally in the conus and the features suggestive of dermoid. He underwent surgical intervention during surgery lesion was dorsally exophytic containing cheesy material with hairs, excision of dermoid along capsule was carried our successfully. Pertinent literature and management of exophytic conus dermoid is discussed briefly.
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Klein JP. Imaging of progressive weakness or numbness of central or peripheral origin. HANDBOOK OF CLINICAL NEUROLOGY 2017; 136:923-37. [PMID: 27430450 DOI: 10.1016/b978-0-444-53486-6.00047-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Weakness and numbness occur in a variety of patterns that reflect injury to different parts of the central and peripheral nervous system. Progressive symptoms most often signify an underlying structural or degenerative problem. Familiarity with the major descending motor and ascending sensory tracts of the central nervous system, as well as radicular (dermatome and myotome) and peripheral nerve anatomy, is essential. Damage to these tracts and nerve fibers produces characteristic clinical symptoms and signs. Imaging, when used in a hypothesis-driven way, can be a valuable adjunct to the clinical history and physical examination. One of the most useful aspects of imaging is that it allows for differentiation of edema and inflammation from gliosis and atrophy, both of which can be associated with progressive weakness or numbness. Compression of nervous system structures by nonnervous system tissue can also be easily detected. The spectrum of diseases and imaging abnormalities associated with progressive weakness and numbness is highlighted in this review via a series of illustrative cases. In each case, anatomic localization and the key imaging findings are emphasized.
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Affiliation(s)
- Joshua P Klein
- Departments of Neurology and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Abstract
To investigate effects of surgical treatment on adult tethered cord syndrome (TCS).A retrospective analysis of 82 adult patients (17 male cases, 82% and 24 female cases, 59%) with TCS treated by surgery was conducted between March, 2005 and December, 2015, with an average age of 31.6 years and average disease course of 6.7 years. All the 82 cases of patients received nerve electrophysiology monitoring assisted microsurgery. After surgery, all patients were followed up for an average of 2.5 years. Surgical effects were evaluated according to Hoffman grading system. As this is just a retrospective study that does not involve any interventions, ethical approval was not necessary according to the rules of the hospital.All patients were followed up, no death occurred. According to Hoffman grading system, the neurologic symptoms were improved in 22 patients (27%), stabilized in 60 patients (73%). Of 10 cases with lipoma tethered spinal cord, corresponding symptoms were improved in 2 cases. Of 32 cases with tethered spinal cord caused by dermoid cyst and epidermoid cyst, the symptoms were improved in 6 cases. Of 40 cases without occupying lesions of tethered spinal cord, the symptoms were improved in 14 cases. Besides, there was no deteriorated case.Surgical treatment on adult patients with TCS can improve the neurologic deficits which are associated with the course of disease, early treatment has much better curative effect.
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Affiliation(s)
- Jun Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xiangyi Kong
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA
| | - Zhimin Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Tianyu Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yongning Li
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Nakashima H, Imagama S, Matsui H, Yukawa Y, Sato K, Kanemura T, Kamiya M, Ito K, Matsuyama Y, Ishiguro N, Kato F. Comparative Study of Untethering and Spine-Shortening Surgery for Tethered Cord Syndrome in Adults. Global Spine J 2016; 6:535-41. [PMID: 27555994 PMCID: PMC4993609 DOI: 10.1055/s-0035-1569004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/22/2015] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective multicenter study. OBJECTIVE Although untethering surgery has been a standard treatment in patients with adult tethered cord syndrome (TCS), spine-shortening osteotomy (SSO) has recently been performed as an alternative technique. The purpose of this study was to compare the clinical outcomes of the two procedures for TCS in adults. METHODS Fourteen patients (37.7 ± 12.5 years) with TCS were enrolled at 6 hospitals. Their clinical charts, operative records, and follow-up data were reviewed. The categories of tethering lesions were tight terminal filum in 1 patient, lipoma in 5 patients, and lipomyelomeningocele in 8 patients. Eleven patients underwent untethering surgery, and 3 patients underwent SSO surgery. RESULTS There were no significant differences in age, sex, types of preoperative symptoms, or duration of follow-up between the two groups. The preoperative duration of symptoms was significantly longer (25 ± 12.4 years) and the percentage of those with prior surgery was higher in the SSO group (66.7%). The preoperative pathology was lipomeningocele in all SSO group and lipoma or tight terminal filum in the untethering group. Cerebrospinal fluid leakage and urinary infection occurred in 1 patient each among those with untethering, and massive intraoperative bleeding occurred in 1 patient with SSO. SSO provided better clinical improvement than untethering surgery (p = 0.003). CONCLUSIONS Based on this small retrospective case series, SSO appears to provide clinical improvement at least comparable to the untethering procedure, especially in more challenging cases.
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Affiliation(s)
- Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan,Address for correspondence Shiro Imagama, MD, PhD Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine65 Tsurumai, Showa-ku, Nagoya, Aichi 466-8560Japan
| | - Hiroki Matsui
- Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yasutsugu Yukawa
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Nagoya, Japan
| | - Koji Sato
- Department of Orthopedic Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Tokumi Kanemura
- Department of Orthopedic Surgery, Konan Kosei Hospital, Aichi, Japan
| | - Mitsuhiro Kamiya
- Department of Orthopedic Surgery, Aichi Medical University, Aichi, Japan
| | - Kenyu Ito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Matsuyama
- Department of Orthopedic Surgery, Hamamatsu Medical University, Shizuoka, Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fumihiko Kato
- Department of Orthopedic Surgery, Chubu Rosai Hospital, Nagoya, Japan
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Tyagi R, Kloepping C, Shah S. Spinal cord stimulation for recurrent tethered cord syndrome in a pediatric patient: case report. J Neurosurg Pediatr 2016; 18:105-10. [PMID: 26942269 DOI: 10.3171/2015.12.peds14645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a patient with a lipomyelomeningocele and worsening back pain due to recurrent tethered cord syndrome. Because of the increased risk and unlikely improvement in symptoms with repeated surgical untethering, she was offered an alternative treatment with a trial of dorsal spinal cord stimulation. She had an excellent response to the percutaneous trial, and a permanent implant was placed, with good initial results. The authors review her case as well as the treatment options, indications, and outcomes for recurrent tethered cord syndrome.
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Affiliation(s)
| | - Carolyn Kloepping
- Anesthesia, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Shruti Shah
- Anesthesia, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Mariniello G, Malacario F, Dones F, Severino R, Ugga L, Russo C, Elefante A, Maiuri F. Sudden post-traumatic sciatica caused by a thoracic spinal meningioma. Neuroradiol J 2016; 29:390-2. [PMID: 27316567 DOI: 10.1177/1971400916655479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Spinal meningiomas usually present with slowly progressive symptoms of cord and root compression, while a sudden clinical onset is very rare. A 35-year-old previously symptom-free woman presented sudden right sciatica and weakness of her right leg following a fall with impact to her left foot. A neurological examination showed paresis of the right quadriceps, tibial and sural muscles, increased bilateral knee and ankle reflexes and positive Babinski sign. Magnetic resonance imaging (MRI) revealed the presence of a spinal T11 meningioma in the left postero-lateral compartment of the spinal canal; at this level, the spinal cord was displaced to the contralateral side with the conus in the normal position. At surgery, a meningioma with dural attachment of the left postero-lateral dural surface was removed. The intervention resulted in rapid remission of both pain and neurological deficits. Spinal meningiomas may exceptionally present with sudden pain and neurological deficits as result of tumour bleeding or post-traumatic injury of the already compressed nervous structures, both in normal patients and in those with conus displacement or tethered cord. In this case, the traumatic impact of the left foot was transmitted to the spine, resulting in stretching of the already compressed cord and of the contralateral lombosacral roots. This case suggests that low thoracic cord compression should be suspected in patients with post-traumatic radicular leg pain with normal lumbar spine MRI.
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Affiliation(s)
- Giuseppe Mariniello
- Department of Neurosciences and Reproductive and Odontostomatologic Sciences, Neurosurgical Clinic, 'Federico II' University, Naples, Italy
| | - Francesca Malacario
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Flavia Dones
- Department of Neurosciences and Reproductive and Odontostomatologic Sciences, Neurosurgical Clinic, 'Federico II' University, Naples, Italy
| | - Rocco Severino
- Department of Neurosciences and Reproductive and Odontostomatologic Sciences, Neurosurgical Clinic, 'Federico II' University, Naples, Italy
| | - Lorenzo Ugga
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Camilla Russo
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Andrea Elefante
- Department of Advanced Biomedical Sciences, 'Federico II' University, Naples, Italy
| | - Francesco Maiuri
- Department of Neurosciences and Reproductive and Odontostomatologic Sciences, Neurosurgical Clinic, 'Federico II' University, Naples, Italy
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Hashimoto K, Tsubakino T, Hoshikawa T, Nakagawa T, Inawashiro T, Kokubun S, Itoi E, Tanaka Y. Elderly-onset degenerative "lumbar spondylotic myelopathy" in a patient with a low-placed spinal cord successfully treated by laminotomy: a case report. Clin Case Rep 2016; 3:1021-5. [PMID: 26734139 PMCID: PMC4693702 DOI: 10.1002/ccr3.424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/31/2015] [Accepted: 09/28/2015] [Indexed: 11/08/2022] Open
Abstract
The authors report a rare case of elderly-onset "lumbar spondylotic myelopathy" occurred on a low-placed spinal cord compressed at multiple levels with thickened ligamenta flava. A posterior decompression surgery could alleviate neurological symptoms successfully instead of untethering of the spinal cord, a widely accepted surgery for tethered cord.
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Affiliation(s)
- Ko Hashimoto
- Department of Orthopeedic Surgery Tohoku Central Hospital Yamagata Japan; Department of Orthopaedic Surgery Graduate School of Medicine Tohoku University Sendai Miyagi Japan
| | - Takumi Tsubakino
- Department of Orthopeedic Surgery Tohoku Central Hospital Yamagata Japan
| | - Takeshi Hoshikawa
- Department of Orthopeedic Surgery Tohoku Central Hospital Yamagata Japan
| | - Tomowaki Nakagawa
- Department of Orthopeedic Surgery Tohoku Central Hospital Yamagata Japan
| | - Takashi Inawashiro
- Department of Orthopeedic Surgery Tohoku Central Hospital Yamagata Japan
| | - Shoichi Kokubun
- Research Center for Spine and Spinal Cord Disorders National Hospital Organization Sendai-Nishitaga Hospital Sendai Miyagi Japan
| | - Eiji Itoi
- Department of Orthopaedic Surgery Graduate School of Medicine Tohoku University Sendai Miyagi Japan
| | - Yasuhisa Tanaka
- Department of Orthopeedic Surgery Tohoku Central Hospital Yamagata Japan
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Spinal cord detethering in children with tethered cord syndrome and Chiari type 1 malformations. J Clin Neurosci 2015; 22:1749-52. [DOI: 10.1016/j.jocn.2015.05.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/22/2015] [Indexed: 02/07/2023]
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An Unusual Presentation of Adult Tethered Cord Syndrome Associated with Severe Chest and Upper Back Pain. Case Rep Orthop 2015; 2015:926185. [PMID: 26442162 PMCID: PMC4579311 DOI: 10.1155/2015/926185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/27/2015] [Accepted: 09/01/2015] [Indexed: 11/17/2022] Open
Abstract
Adult tethered cord syndrome (ATCS) is a rare entity that usually presents with multiple neurological symptoms, including lower extremity pain, backache, lower extremity muscle weakness, and bowel/bladder disturbances. Prompt surgical treatment is often necessary to avoid permanent sequelae. We report a 63-year-old man with sudden-onset severe right chest and upper back pain, followed by urinary retention. His initial workup included computed tomography of the abdomen and pelvis, which showed a presacral mass. His symptom-driven neurological workup focused on the cervical and thoracic spine, the results of which were normal. Pelvic radiographs and magnetic resonance imaging of the lumbosacral spine showed spina bifida occulta, meningocele, and presacral masses consistent with a teratomatous tumor. His symptoms, except for urinary retention, improved dramatically with surgical treatment. The excised specimen contained a teratomatous lesion plus an organized hematoma. Hematoma formation was suspected as the trigger of his sudden-onset right chest and upper back pain.
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Yang T, Wu L, Fang J, Yang C, Deng X, Xu Y. Clinical presentation and surgical outcomes of intramedullary neurenteric cysts. J Neurosurg Spine 2015; 23:99-110. [PMID: 25909275 DOI: 10.3171/2014.11.spine14352] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Intramedullary neurenteric cysts (NECs) are exceedingly rare lesions and have been previously reported in case reports. The aim of this study was to determine the clinical manifestations, radiological features, and long-term prognosis of patients with such lesions.
METHODS
The authors retrospectively reviewed the records of 13 patients with an intramedullary NEC. Each patient underwent MRI, laminotomy, and microsurgery. The accurate diagnosis was based on imaging and pathology findings. Each patient's follow-up status was determined through individual office visits and a structured telephone interview.
RESULTS
The series included 7 male and 6 female patients. Progressive or intermittent motor deficit was the main symptom associated with or without pain or sensory disturbance. Five cysts were located in the cervical cord, 1 in the cervicothoracic cord, 3 in the thoracic cord, and 4 in the conus medullaris. Concurrent malformations included scoliosis (3 cases), fusion of rib (1 case), enlarged spinal canal (1 case), tethered spinal cord (1 case), and ectocardia (1 case). Gross-total resection of the cyst was achieved in 8 cases, and subtotal resection (STR) was achieved in 5 cases. All patients were followed up, with a mean duration of 66.5 months. Cyst recurrence was observed in 4 cases after STR. In 2 cases the patients underwent reoperation; the other 2 patients remained clinically stable and did not undergo reoperation. At the last evaluation, neurological function was improved in 11 patients and remained stable in 2 patients.
CONCLUSIONS
Intramedullary NECs should be considered in the differential diagnosis of a middle-aged patient with intermittent neurological symptoms and concurrent malformations. Early surgery is advocated to prevent permanent neurological deficits. When gross-total resection cannot be achieved, maximally safe removal under the protection of intraoperative neuromonitoring is advised. Because of the high risk of cyst recurrence, routine follow-up MRI is needed. If a residual cyst shows obvious regrowth and results in neurological deficits, timely reoperation with a goal of STR should be performed.
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Affiliation(s)
- Tao Yang
- 1Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital; and
| | - Liang Wu
- 1Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital; and
| | - Jingyi Fang
- 2Department of Neuropathology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Chenlong Yang
- 1Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital; and
| | - Xiaofeng Deng
- 1Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital; and
| | - Yulun Xu
- 1Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital; and
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Lower urinary tract dysfunction in patients with peripheral nervous system lesions. HANDBOOK OF CLINICAL NEUROLOGY 2015; 130:203-24. [PMID: 26003246 DOI: 10.1016/b978-0-444-63247-0.00012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
The prevalence of lower urinary tract (LUT) dysfunction in peripheral nervous system (PNS) disorders is larger than in comparable control populations. This is particularly true for polyneuropathies with autonomic nervous system involvement, and for localized lesions with LUT innervation. LUT symptoms may be the guide to the diagnosis of processes localized in the lumbosacral spinal canal (as in cauda equina syndrome), and in the pelvis. Typical LUT dysfunctions (LUTD) caused by PNS involvement include bladder and sphincter hypoactivity with poor emptying, and incontinence. Paradoxically, bladder overactivity may also occur in pure PNS lesions. The acute cauda equina syndrome is an emergency requiring magnetic resonance imaging and surgery; in chronic neurogenic LUTD due to PNS involvement, the diagnosis of the lesion may be clarified by clinical neurophysiologic testing. Other important causes of neurogenic LUT dysfunction are perineoabdominal and pelvic surgeries. Surgeons are devising nerve-sparing techniques to prevent such major and often persistent complications in patients who are otherwise cured of the underlying disease. LUTD significantly affects the quality of life in patients and may lead to recurring urinary infections and upper urinary tract involvement. Thorough assessment of LUT function by urodynamics may be necessary in patients who are not improved by simple conservative measures.
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Abstract
BACKGROUND Tethered cord syndrome is a well-defined condition, the management of which is fairly uniform. In contrast, occult tethered cord syndrome is a recently defined entity, where the management is still controversial. The pathophysiology is unclear and may be conceptually incongruent with current understanding of typical tethered cord syndrome. Presentation, investigation, and management of this condition are reviewed, and current understanding is presented. PURPOSE The aim of this study is to review the presentation, pathophysiology, investigation, and management of occult tethered cord syndrome. METHODS Literature review. RESULTS Patients with occult tethered cord syndrome presents predominantly with urologic symptoms. Adult and pediatric patients vary slightly in their presentation with a higher incidence of pain in the former and incontinence in the latter. Operative management for these patients is associated with consistent improvement in urologic function in particular, although surgery is also associated with risk of worsening symptoms. The natural history of untreated patients is unknown. CONCLUSIONS As occult tethered cord syndrome becomes increasingly recognized, it is important to be aware of the potential benefits of operative intervention for appropriately selected patients. Given that the natural history of this entity remains unknown, a clinical trial is currently underway that may assist in defining the role for operative management in treating this condition.
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Klekamp J. Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results. J Neurosurg Spine 2013; 19:12-26. [DOI: 10.3171/2013.3.spine121063] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Object
Surgery of intramedullary tumors is established as the treatment of choice for these challenging lesions. This study presents a detailed analysis of risk factors for surgical morbidity and data on long-term results for intramedullary tumors.
Methods
Among 1317 patients with tumors of the spinal canal treated between 1980 and 2012, 278 patients with intramedullary tumors are presented. A total of 225 of these patients underwent 246 operations for treatment of 250 tumors. The mean patient age was 41 ± 17 years (range 3 weeks to 83 years). Patients underwent follow-up through outpatient visits and questionnaires with a mean follow-up of 41 ± 53 months. Tumors were subdivided into 3 groups: displacing tumors (Type A, n = 162), infiltrating tumors (Type B, n = 80), and nonproliferating tumors (Type C, n = 8). A gross-total resection (GTR) was attempted for every tumor except for Type C lipomas. Participating surgeons were divided into 3 groups according to the number of operations they performed. Short-term results were determined for individual symptoms and the modified McCormick Scale, whereas tumor recurrence rates were calculated with Kaplan-Meier statistics.
Results
Overall, 83.3% of Type A tumors underwent GTR compared with 22.5% of Type B and none in Type C. Gross-total resection rates increased throughout the study period and correlated significantly with surgical experience. A worsened neurological state after surgery was seen in 61% of patients. This deterioration was transient in 41.5% and was a common observation after GTR. Permanent morbidity (19.5%) was lowest after GTR and correlated significantly with surgical experience and the preoperative neurological state. Further analysis showed that patients with tumors of thoracic levels, tumor hemorrhages, and malignant and recurrent tumors were at a higher risk for permanent morbidity. In the long term, tumor recurrence rates for ependymomas and benign astrocytomas correlated significantly with the amount of resection. Long-term morbidity affected 3.7% with a postoperative myelopathy related to cord tethering at the level of surgery and 21.9% in form of neuropathic pain syndromes. The rate of postsurgical cord tethering could be lowered significantly by using pia sutures after tumor resection. Neuropathic pain syndromes were more common after surgery for tumors with associated syringomyelia or those located in the cervical cord.
Conclusions
Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Gross-total resection is possible for the majority of benign pathologies. Cervical tumors are associated with higher GTR and lower permanent morbidity rates compared with thoracic tumors. Surgery on intramedullary tumors should be performed by neurosurgeons who deal with these lesions on a regular basis as considerable experience is required to achieve high GTR rates and to limit rates of permanent morbidity.
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