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Nawashiro T, Kurimoto M, Nagakura M, Kato M, Aoki K, Saito R. Comparison of the inter-laminar approach and laminotomy open approach for filum terminale lipoma: A retrospective analysis. Childs Nerv Syst 2024:10.1007/s00381-024-06507-4. [PMID: 38958731 DOI: 10.1007/s00381-024-06507-4] [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: 01/13/2024] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Filum terminale lipoma (FTL) causes spinal-cord tethering and is associated with tethered-cord syndrome, which is treated by dissection of the entrapment. The conventional treatment for FTL involves dissection of the spinal cord through a laminotomy open approach (LOA). However, in recent years, the interlaminar approach (ILA) has gained popularity as a minimally invasive surgery. This study compares the effectiveness of the minimally invasive ILA with the conventional LOA in treating FTL. METHODS We retrospectively evaluated data on the ILA and LOA for FTL at our center. In total, 103 participants were enrolled, including 55 in the ILA group and 48 in the LOA group. RESULTS The ILA required significantly less surgical time and resulted in less blood loss. The improvement rate of symptoms in symptomatic patients was 84%, and for urinary symptoms and abnormal urodynamic study findings, it was 77%. The postoperative maintenance rate for asymptomatic patients was 100%. Postoperative complications of ILA included delayed wound healing in two patients (3.6%). CONCLUSION Compared with LOA, ILA offers advantages in terms of shorter operative time and less blood loss, with no significant difference in long-term symptom-improvement rates between the groups.
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Affiliation(s)
- Tomoki Nawashiro
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Michihiro Kurimoto
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan.
| | - Masamune Nagakura
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Mihoko Kato
- Department of Neurosurgery, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Kousuke Aoki
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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2
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Findlay MC, Tenhoeve S, Terry SA, Iyer RR, Brockmeyer DL, Kelly MP, Kestle JRW, Gonda D, Ravindra VM. Disparities in indications and outcomes reporting for pediatric tethered cord surgery: The need for a standardized outcome assessment tool. Childs Nerv Syst 2024; 40:1111-1120. [PMID: 38072858 PMCID: PMC10972940 DOI: 10.1007/s00381-023-06246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/29/2023] [Indexed: 03/28/2024]
Abstract
PURPOSE Tethered cord syndrome (TCS) is characterized by abnormal attachment of the spinal cord neural elements to surrounding tissues. The most common symptoms include pain, motor or sensory dysfunction, and urologic deficits. Although TCS is common in children, there is a significant heterogeneity in outcomes reporting. We systematically reviewed surgical indications and postoperative outcomes to assess the need for a grading/classification system. METHODS PubMed and EMBASE searches identified pediatric TCS literature published between 1950 and 2023. Studies reporting surgical interventions, ≥ 6-month follow-up, and ≥ 5 patients were included. RESULTS Fifty-five studies representing 3798 patients were included. The most commonly reported non-urologic symptoms were nonspecific lower-extremity motor disturbances (36.4% of studies), lower-extremity/back pain (32.7%), nonspecific lower-extremity sensory disturbances (29.1%), gait abnormalities (29.1%), and nonspecific bowel dysfunction/fecal incontinence (25.5%). Urologic symptoms were most commonly reported as nonspecific complaints (40.0%). After detethering surgery, retethering was the most widely reported non-urologic outcome (40.0%), followed by other nonspecific findings: motor deficits (32.7%), lower-extremity/back/perianal pain (18.2%), gait/ambulation function (18.2%), sensory deficits (12.7%), and bowel deficits/fecal incontinence (12.7%). Commonly reported urologic outcomes included nonspecific bladder/urinary deficits (27.3%), bladder capacity (20.0%), bladder compliance (18.2%), urinary incontinence/enuresis/neurogenic bladder (18.2%), and nonspecific urodynamics/urodynamics score change (16.4%). CONCLUSION TCS surgical literature is highly variable regarding surgical indications and reporting of postsurgical outcomes. The lack of common data elements and consistent quantitative measures inhibits higher-level analysis. The development and validation of a standardized outcomes measurement tool-ideally encompassing both patient-reported outcome and objective measures-would significantly benefit future TCS research and surgical management.
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Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Samuel Tenhoeve
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Skyler A Terry
- College of Social and Behavioral Sciences, University of Utah, Salt Lake City, UT, USA
| | - Rajiv R Iyer
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Douglas L Brockmeyer
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Michael P Kelly
- Division of Pediatric Orthopedics, Rady Children's Hospital, San Diego, CA, USA
| | - John R W Kestle
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - David Gonda
- Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
- Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
- Department of Neurological Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
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3
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Cerebrospinal fluid leakage after intradural spinal surgery in children. Childs Nerv Syst 2023; 39:1013-1019. [PMID: 36790491 PMCID: PMC10160141 DOI: 10.1007/s00381-022-05797-w] [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: 10/12/2022] [Accepted: 12/08/2022] [Indexed: 02/16/2023]
Abstract
PURPOSE This study aimed to establish the incidence of CSF leakage in children and associated complications after intradural spinal surgery in three tertiary neurosurgical referral centers and to describe the treatment strategies applied. METHODS Patients of 18 years or younger who underwent intradural spinal surgery between 2015 and 2021 in three tertiary neurosurgical referral centers were included. Patients who died or were lost to follow-up within six weeks after surgery were excluded. The primary outcome measure was CSF leakage within six weeks after surgery, defined as leakage of CSF through the skin. Secondary outcome measures included the presence of pseudomeningocele (PMC), meningitis, and surgical site infection (SSI). RESULTS We included a total of 75 procedures, representing 66 individual patients. The median age in this cohort was 5 (IQR = 0-13 years. CSF leakage occurred in 2.7% (2/75) of procedures. It occurred on days 3 and 21 after the index procedure, respectively. One patient was treated with a pressure bandage and an external lumbar drain on day 4 after diagnosis of the leak, and the other was treated with wound revision surgery on day 1 after the leak occurred. In total, 1 patient developed a PMC without a CSF leak which was treated with wound revision surgery. SSI occurred in 10.7%, which included both cases of CSF leak. CONCLUSIONS CSF leakage after intradural spinal surgery in the pediatric population is relatively rare (2.7%). Nevertheless, the clinical consequences with respect to secondary complications such as infection and the necessity for invasive treatment are serious.
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Kankam SB, Amini E, Khoshnevisan K, Khoshnevisan A. Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:293-299. [PMID: 35811251 DOI: 10.1016/j.neucie.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/29/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery. MATERIALS AND METHODS We conducted a single-center, double-blind, randomized -controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone (CP-A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP-A group (n = 36, 50%) and CP+A group (n = 36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position + dose of acetazolamide 20 mg/kg/day in 3-4 divided doses for 7 days), and CP-A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide). RESULTS Baseline characteristics between the two groups showed no significant differences: Sex (P < .637), Age (P < .988) and previous CNS operation at other location besides the spine (P < .496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36 (11.11%) of CP-A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081-2.748; OR = 0.471; P < .402; Adjusted P < .247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P < .489) and type of operation (P < .465). CONCLUSION Acetazolamide has no positive effect in controlling CSF leak after dural opening/dural tear in adult patients who undergo spinal surgery, when we considered alongside the one-week prone position. Therefore, acetazolamide administration may not be essential for postoperative spinal surgery for dural tear. Prospective studies involving a larger sample size may be needed to track long-term acetazolamide complications on patients with CSF leak.
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Affiliation(s)
- Samuel Berchi Kankam
- Department of Neurosurgery, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Amini
- Pharmaceutical Care Department, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamyar Khoshnevisan
- Biosensor Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshnevisan
- Department of Neurosurgery, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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5
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Kankam SB, Amini E, Khoshnevisan K, Khoshnevisan A. Investigating acetazolamide effectiveness on CSF leak in adult patients after spinal surgery. Neurocirugia (Astur) 2021. [DOI: 10.1016/j.neucir.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kanematsu R, Hirokawa D, Usami K, Ogiwara H. Is the Postoperative Horizontal Decubitus Position Following Transection of a Tight Filum Terminale in Pediatric Patients Necessary? - A Retrospective Cohort Study. Neurol Med Chir (Tokyo) 2020; 60:252-255. [PMID: 32295981 PMCID: PMC7246225 DOI: 10.2176/nmc.oa.2019-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
After untethering surgery of a tethered spinal cord of a tight filum terminale, patients are usually kept in the horizontal decubitus position to prevent cerebrospinal fluid (CSF) leakage. However, the optimal period for keeping these patients in this position has not been established yet. Surgical results in two groups of pediatric patients with a tight filum terminale were retrospectively analyzed. Group A was maintained in the horizontal decubitus position for 72 h and group B was managed without being kept in this position postoperatively. A total of 313 patients underwent sectioning of a tight filum terminale. Of these patients, 144 were maintained horizontally for 72 h postoperatively (group A) and 169 were managed without this position (group B). Among the patients who were maintained horizontally for 72 h, one (0.7%) developed pseudomeningocele. No patients experienced CSF leakage in this group. Among the patients who were not horizontal, one (0.6%) developed CSF leakage and one (0.6%) developed pseudomeningocele. Maintaining patients without restriction of their position does not appear to change the rate of postoperative CSF leakage or pseudomeningocele. This suggests that maintaining patients horizontally after transection of a tight filum terminale is not necessary for preventing CSF leakage.
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Affiliation(s)
- Ryo Kanematsu
- Division of Neurosurgery, National Center for Child Health and Development
| | - Daisuke Hirokawa
- Division of Neurosurgery, National Center for Child Health and Development
| | - Kenichi Usami
- Division of Neurosurgery, National Center for Child Health and Development
| | - Hideki Ogiwara
- Division of Neurosurgery, National Center for Child Health and Development
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Minimizing CSF Leak and Wound Complications in Tethered Cord Surgery with Prone Positioning: Outcomes in 350 Patients. World Neurosurg 2020; 137:e610-e617. [PMID: 32088374 DOI: 10.1016/j.wneu.2020.02.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND We document the results of a protocol to reduce the incidence of cerebrospinal fluid (CSF) leak and other wound complications in patients undergoing tethered cord surgery (TCS). METHODS Data from all patients undergoing TCS between January 2009 and April 2019 were reviewed retrospectively. Diagnosis (high risk or low risk; based on the presence of fascial and dural defects at surgery), type of graft used for dural or fascial repair, and CSF leak and other wound complications in the postoperative period were noted. All patients were nursed in the prone position with elevation of the foot end of the bed (Trendelenburg position) for at least 5 days after surgery with a subfascial drain in place. RESULTS Of a total of 350 patients (191 high risk; 159 low risk), CSF leak from the wound was noted in 16 (4.5%). All but 4 of these patients were managed with wound suturing with or without insertion of a subcutaneous drain with continued nursing in the prone and Trendelenburg position. Two patients had meningitis and 3 patients had wound infection. Multivariate analysis revealed that the use of synthetic grafts (P < 0.000) and inability to close the dura (P = 0.02) were the only significant risk factors for CSF wound leak. Wound infections and/or dehiscence were noted in 17 (4.8%) other patients. CONCLUSION Postoperative prone nursing with Trendelenburg position minimizes the incidence of CSF leak and other wound complications.
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8
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Alexiades NG, Shao B, Saiman L, Feldstein N, Anderson RCE. High Prevalence of Gram-Negative Rod and Multi-Organism Surgical Site Infections after Pediatric Complex Tethered Spinal Cord Surgery: Preliminary Report from a Single-Center Study. Pediatr Neurosurg 2020; 55:92-100. [PMID: 32674104 DOI: 10.1159/000508753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 05/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common complications following pediatric complex tethered spinal cord release. This patient population is similar in some ways to the neuromuscular scoliosis population, in which higher-than-expected rates of gram-negative SSIs have been identified. METHODS We conducted a single-center retrospective chart review of all patients who underwent complex tethered spinal cord release over a 10-year period between 2007 and 2017. RESULTS A total of 69 patients were identified, with 10 documented SSIs (14%). 50% of the SSIs were polymicrobial or included at least 1 gram-negative organism. Among the organisms isolated, 3 were fully or -partially resistant to cefazolin, the most common antibiotic prophylaxis in this population. CONCLUSION Among children undergoing complex tethered spinal cord release, gram-negative and polymicrobial infections are a significant cause of SSIs. Although further multicenter data are needed, these findings suggest that standard antibiotic prophylaxis with cefazolin may not be sufficient.
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Affiliation(s)
- Nikita G Alexiades
- Department of Neurological Surgery, Columbia University, New York, New York, USA,
| | - Belinda Shao
- Rutgers University Medical School, Newark, New Jersey, USA
| | - Lisa Saiman
- Department of Pediatric Infectious Disease, Columbia University, New York, New York, USA
| | - Neil Feldstein
- Department of Neurological Surgery, Columbia University, New York, New York, USA
| | - Richard C E Anderson
- Department of Neurological Surgery, Columbia University, New York, New York, USA
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9
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Alexiades NG, Ahn ES, Blount JP, Brockmeyer DL, Browd SR, Grant GA, Heuer GG, Hankinson TC, Iskandar BJ, Jea A, Krieger MD, Leonard JR, Limbrick DD, Maher CO, Proctor MR, Sandberg DI, Wellons JC, Shao B, Feldstein NA, Anderson RCE. Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study. J Neurosurg Pediatr 2018; 22:701-709. [PMID: 30215584 DOI: 10.3171/2018.6.peds18243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEComplications after complex tethered spinal cord (cTSC) surgery include infections and cerebrospinal fluid (CSF) leaks. With little empirical evidence to guide management, there is variability in the interventions undertaken to limit complications. Expert-based best practices may improve the care of patients undergoing cTSC surgery. Here, authors conducted a study to identify consensus-driven best practices.METHODSThe Delphi method was employed to identify consensual best practices. A literature review regarding cTSC surgery together with a survey of current practices was distributed to 17 board-certified pediatric neurosurgeons. Thirty statements were then formulated and distributed to the group. Results of the second survey were discussed during an in-person meeting leading to further consensus, which was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).RESULTSSeventeen consensus-driven best practices were identified, with all participants willing to incorporate them into their practice. There were four preoperative interventions: (1, 2) asymptomatic AND symptomatic patients should be referred to urology preoperatively, (3, 4) routine preoperative urine cultures are not necessary for asymptomatic AND symptomatic patients. There were nine intraoperative interventions: (5) patients should receive perioperative cefazolin or an equivalent alternative in the event of allergy, (6) chlorhexidine-based skin preparation is the preferred regimen, (7) saline irrigation should be used intermittently throughout the case, (8) antibiotic-containing irrigation should be used following dural closure, (9) a nonlocking running suture technique should be used for dural closure, (10) dural graft overlay should be used when unable to obtain primary dural closure, (11) an expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF, (12) paraxial muscles should be closed as a layer separate from the fascia, (13) routine placement of postoperative drains is not necessary. There were three postoperative interventions: (14) postoperative antibiotics are an option and, if given, should be discontinued within 24 hours; (15) patients should remain flat for at least 24 hours postoperatively; (16) routine use of abdominal binders or other compressive devices postoperatively is not necessary. One intervention was prioritized for additional study: (17) further study of additional gram-negative perioperative coverage is needed.CONCLUSIONSA modified Delphi technique was used to develop consensus-driven best practices for decreasing wound complications after cTSC surgery. Further study is required to determine if implementation of these practices will lead to reduced complications. Discussion through the course of this study resulted in the initiation of a multicenter study of gram-negative surgical site infections in cTSC surgery.
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Affiliation(s)
- Nikita G Alexiades
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Edward S Ahn
- 2Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Blount
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurosurgery, University of Washington Seattle Children's Hospital, Seattle, Washington
| | - Gerald A Grant
- 6Department of Neurosurgery, Stanford University, Stanford, California
| | - Gregory G Heuer
- 7Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Todd C Hankinson
- 8Department of Pediatric Neurosurgery, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Bermans J Iskandar
- 9Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Andrew Jea
- 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark D Krieger
- 11Department of Neurological Surgery, USC Keck School of Medicine/Children's Hospital of Los Angeles, California
| | - Jeffrey R Leonard
- 12Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - David D Limbrick
- 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- 14Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Mark R Proctor
- 15Department of Neurosurgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - David I Sandberg
- 16Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center, Houston, Texas
| | - John C Wellons
- 17Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Belinda Shao
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
- 18Rutgers New Jersey Medical School, Newark, New Jersey
| | - Neil A Feldstein
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Richard C E Anderson
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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Hayashi T, Kimiwada T, Kohama M, Shirane R, Tominaga T. Minimally Invasive Surgical Approach to Filum Lipoma. Neurol Med Chir (Tokyo) 2018; 58:132-137. [PMID: 29367470 PMCID: PMC5929922 DOI: 10.2176/nmc.oa.2017-0200] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Filum terminale lipoma (FTL) causes various spinal symptoms known as tethered cord syndrome. The treatment for FTL is surgical untethering by sectioning the FTL, which can prevent symptom progression and often results in improvement of symptoms. This report describes a minimally invasive surgical strategy that we have introduced for FTL sectioning. The pediatric patients with FTL since 2007 were treated using this minimally invasive surgical strategy, which we refer to as an interlaminar approach (ILA). In summary, the surgical technique involves: minimal skin incision to expose the unilateral ligamentum flavum in the lower lumbar region; ligamentum flavum incision to expose the dural sac, and dural incision followed by identification and sectioning of the filum. Postoperatively, no bed rest was required. Prior to introducing ILA, we had used standard one level laminectomy/laminotomy (LL) with more than 1 week of postsurgical bed rest until 2007, providing an adequate control group for the benefit of the ILA. A total of 49 consecutive patients were treated using ILA. While 37 patients were treated using LL. Surgical complications that need surgery were seen only in one patient, who developed cerebrospinal fluid (CSF) leak in LL patients. No retethering or additional neurological symptoms were seen during follow-up. All patients complained of minimal postsurgical back pain, but no patients required postoperative bed rest in ILA patients, while LL patients need postsurgical bed rest because of back pain. The ILA strategy provides the advantage of a minimal tissue injury, associated with minimal postoperative pain, blood loss, and bed rest.
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Affiliation(s)
| | | | - Misaki Kohama
- Department of Neurosurgery, Miyagi Children's Hospital
| | - Reizo Shirane
- Department of Neurosurgery, Miyagi Children's Hospital
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
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Poonia S, Graber S, Corbett Wilkinson C, O'neill BR, Handler MH, Hankinson TC. Outcome of hospital discharge on postoperative Day 1 following uncomplicated tethered spinal cord release. J Neurosurg Pediatr 2016; 17:651-6. [PMID: 26849810 DOI: 10.3171/2015.10.peds15318] [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
OBJECTIVE Postoperative management following the release of simple spinal cord-tethering lesions is highly variable. As a quality improvement initiative, the authors aimed to determine whether an institutional protocol of discharging patients on postoperative day (POD) 1 was associated with a higher rate of postoperative CSF leaks than the prior protocol of discharge on POD 2. METHODS This was a single-center retrospective review of all children who underwent release of a spinal cord-tethering lesion that was not associated with a substantial fascial or dural defect (i.e., simple spinal cord detethering) during 2 epochs: prior to and following the institution of a protocol for discharge on POD 1. Outcomes included the need for and timing of nonroutine care of the surgical site, including return to the operating room, wound suturing, and nonsurgical evaluation and management. RESULTS Of 169 patients identified, none presented with CSF-related complications prior to discharge. In the preintervention group (n = 113), the postoperative CSF leak rate was 4.4% (5/113). The mean length of stay was 2.3 days. In the postintervention group, the postoperative CSF leak rate was 1.9% (1/53) in the patients with postdischarge follow-up. The mean length of stay in that group was 1.3 days. CONCLUSIONS At a single academic children's hospital, a protocol of discharging patients on POD 1 following uncomplicated release of a simple spinal cord-tethering lesion was not associated with an increased rate of postoperative CSF leaks, relative to the previous protocol. The rates identified are consistent with the existing literature. The authors' practice has changed to discharge on POD 1 in most cases.
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Affiliation(s)
| | - Sarah Graber
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - C Corbett Wilkinson
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - Brent R O'neill
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - Michael H Handler
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - Todd C Hankinson
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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12
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Wellons JC. Editorial: Post-untethering positioning and diuresis. J Neurosurg Pediatr 2016; 17:657-8. [PMID: 26824598 DOI: 10.3171/2015.9.peds15484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- John C Wellons
- Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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13
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Shahjouei S, Hanaei S, Habibi Z, Hoseini M, Ansari S, Nejat F. Randomized clinical trial of acetazolamide administration and/or prone positioning in mitigating wound complications following untethering surgeries. J Neurosurg Pediatr 2016; 17:659-66. [PMID: 26824595 DOI: 10.3171/2015.8.peds15393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE No evidence-based guideline has been approved for the postoperative management of pediatric patients with tethered cord syndrome (TCS). The purpose of this randomized clinical trial was to evaluate the effectiveness of prone positioning and acetazolamide administration on complication rates following spinal cord untethering surgeries. METHODS From October 2012 to February 2015, patients with a primary diagnosis of TCS who were admitted to the Children's Medical Center Hospital of Iran were randomly allocated to 1 of 4 intervention modality groups postoperatively: 1) Group A, acetazolamide administration for 10 days; 2) Group B, prone positioning for 10 days; 3) Group C, acetazolamide administration and prone positioning for 10 days; and 4) Group D, no intervention. CSF leakage, CSF collection, wound dehiscence, operative site infection, and secondary surgical wound repair were considered failure. RESULTS A total of 161 patients were enrolled in this study (Group A, n = 39 [24.2%]; Group B, n = 41 [25.5%]; Group C, n = 39 [24.2%]; and Group D, n = 42 [26.1%]). The overall failure rate was 12.42% (20 patients). Complication rates through pooled analyses were as follows: CSF leakage (n = 9, 5.6%), CSF collection (n = 12, 7.5%), wound dehiscence (n = 2, 1.2%), and infection of operation site (n = 3, 1.9%). Two patients (1.2%) required surgical secondary wound repair due to complications. CSF leakage and collection rates were significantly lower in patients who underwent prone positioning (p = 0.042 and 0.036, respectively). The administration of acetazolamide, either isolated or in combination with prone positioning, not only could not significantly lower the complication rates, but also added the burden of side effects. CONCLUSIONS The current study demonstrates the possible role of prone positioning in mitigating the complication rates subsequent to untethering surgeries. Clinical trial registration no.: NCT01867268 ( clinicaltrials.gov ).
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Affiliation(s)
- Shima Shahjouei
- Department of Neurosurgery, Children's Hospital Medical Center, and
| | - Sara Hanaei
- Department of Neurosurgery, Children's Hospital Medical Center, and
| | - Zohreh Habibi
- Department of Neurosurgery, Children's Hospital Medical Center, and
| | - Mostafa Hoseini
- Department of Statistics and Epidemiology, Tehran University of Medical Science, Tehran, Iran; and
| | - Saeed Ansari
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Farideh Nejat
- Department of Neurosurgery, Children's Hospital Medical Center, and
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