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Kobayashi T, Miyakoshi N, Abe T, Kikuchi K, Abe E, Shimada Y. Surgical technique of spine-shortening vertebral osteotomy for adult tethered cord syndrome: a case report and review of the literature. J Med Case Rep 2023; 17:425. [PMID: 37817238 PMCID: PMC10566082 DOI: 10.1186/s13256-023-04155-x] [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: 07/15/2020] [Accepted: 08/30/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Miyakoshi et al. reported three cases of tethered cord syndrome treated by spine-shortening vertebral osteotomy, which provided relief of the patients' symptoms with no complications. Although the details of these cases were described in a previous report, the surgical technique was not thoroughly explained. In the present report, we describe the details of our procedure with reference to a fourth case. CASE PRESENTATION A 47-year-old Asian woman was admitted to our hospital with a 1-year history of worsening leg numbness and urinary dysfunction. Magnetic resonance imaging revealed a low-lying conus medullaris extending to the level of S2 and surrounded by fat tissue at that level. We diagnosed her condition as adult tethered cord syndrome, and spine-shortening vertebral osteotomy was planned. The target level for the osteotomy was L2. Bilateral pedicle screw implants were placed at L1 and L3 using an anterior-posterior image intensifier. In this procedure, it is essential to use monoaxial screws inserted exactly parallel to the rostral endplates of each vertebral body; this ensures appropriate alignment between the L1 caudal endplate and the L2 osteotomy surface. The upper one-third of the lamina of L2 was resected, and the bilateral two-thirds of the pedicle of L2 was removed with a surgical air drill. After exposure of the lateral side of the L1-2 disc, discectomy was performed with a knife and curette. Following complete discectomy of L1-2, the upper vertebral body of L2 was removed with a surgical air drill. After complete removal of the vertebral body, a straight rod was connected to two screws and applied pressure between the screws. Two polyethylene tapes were applied to the L2 lamina and bilateral rods. CONCLUSION Spine-shortening osteotomy that preserves the caudal one-third of the pedicle and lamina with one-above and one-below instrumentation successfully reduced the spinal cord tension without causing neural damage.
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Affiliation(s)
- Takashi Kobayashi
- Department of Orthopedic Surgery, Akita Kousei Medical Center, 1-1-1 Iijima, Nishifukuro, Akita, 011-0948, Japan.
| | - Naohisa Miyakoshi
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Toshiki Abe
- Department of Orthopedic Surgery, Akita Kousei Medical Center, 1-1-1 Iijima, Nishifukuro, Akita, 011-0948, Japan
| | - Kazuma Kikuchi
- Department of Orthopedic Surgery, Akita Kousei Medical Center, 1-1-1 Iijima, Nishifukuro, Akita, 011-0948, Japan
| | - Eiji Abe
- Department of Orthopedic Surgery, Akita Kousei Medical Center, 1-1-1 Iijima, Nishifukuro, Akita, 011-0948, Japan
| | - Yoichi Shimada
- Department of Orthopedic Surgery, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
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Bowman RM, Lee JY, Yang J, Kim KH, Wang KC. Myelomeningocele: the evolution of care over the last 50 years. Childs Nerv Syst 2023; 39:2829-2845. [PMID: 37417984 DOI: 10.1007/s00381-023-06057-1] [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: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Myelomeningocele (MMC) is one of the representative anomalies in the field of pediatric neurosurgery. During the 50 years of ISPN history, MMC had a tremendous changes in its incidence, clinical management and outcome with advanced understanding of its pathogenesis. We reviewed the changes in MMC during the period. METHODS We reviewed the literature review and collected our experiences. RESULTS During the 50 years, major changes happened in many aspects of MMC including incidence, pathoembryogenesis, folate deficiency, prevention, prenatal diagnosis, mode of delivery, treatment policy with ethical considerations, clinical treatment including fetal surgery, latex allergy, retethering, management outcome, multidisciplinary team approach, and socioeconomic and family issues. CONCLUSIONS There was a great advance in the management and research of MMC during the 50 years. It is a monumental achievement of pediatric neurosurgeons and colleagues of the related fields.
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Affiliation(s)
- Robin M Bowman
- Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Neurosurgery Department, Northwestern University, Chicago, IL, USA
| | - Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeyul Yang
- Department of Neurosurgery, Myongji Hospital, Goyang, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyu-Chang Wang
- Center for Rare Cancers, Neuro-oncology Clinic, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Kyounggi-do, 10408, Republic of Korea.
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Sural S, Goyal A, Garg R, Singh A, Kashyap A, Arora S. Evaluation of vertebral shortening and interbody fusion with short segment pedicle screw fixation for unstable thoracolumbar fractures. J Orthop 2023; 37:15-21. [PMID: 36974098 PMCID: PMC10039110 DOI: 10.1016/j.jor.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 01/30/2023] Open
Abstract
Background Various operative procedures have been described for the treatment of traumatic paraplegia caused by unstable thoracolumbar fractures. We prospectively evaluated interbody fusion (IBF) with SS-PSF in these cases with regard to clinico-radiological outcome with the objectives: (1) Does IBF and short segment pedicle screw fixation (SS-PSF) prevent progression of kyphotic angle after surgery? (2) Can this procedure be safely performed in the setting of acute trauma?. Methods Sixteen patients suffering from traumatic paraplegia caused by acute unstable thoracolumbar fractures were enrolled prospectively and underwent IBF with SS-PSF. They were evaluated for magnitude of shortening in spine, progression of kyphotic angle, and neurological improvement by American spinal injury association scale (ASIA). Results Out of total sixteen, 14 patients were ASIA grade A and 2 were grade C, at the time of presentation. Thirteen out of these 14 remained grade A and one improved to B. Both the patients who had grade C involvement at the time of presentation improved to grade D at one-year follow-up. The mean blood loss was 750 ml (range; 650 ml-1150 ml). Mean kyphotic angle decreased from 20.6° (range; 13° to 37°) preoperatively to 6.2° (range; 3° to 10°) at postoperative day 2 (p = 0.002). Its mean value after 6 months was 6.5° (range; 3° to 11°). The procedure resulted in mean spinal column shortening of 18 mm (range; 16 mm-22 mm) in the spinal column. All the patients achieved bony union by a mean duration of 3.9 months (range; 3 months-6 months). Conclusions IBF with SS-PSF has the shortest possible instrumented construct for thoracolumbar junction fusion done by posterior approach. The interbody fusion for unstable thoracolumbar junction fractures prevents the progression of kyphotic angle post-operatively. Level of evidence Level 4.
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Affiliation(s)
- Sumit Sural
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Arpit Goyal
- SKOP Centre, B-516, Kamla Nagar, Agra, UP, India
| | - Rahul Garg
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Ashwani Singh
- National Heart Institute, East of Kailash, New Delhi, 110065, India
| | - Abhishek Kashyap
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Sumit Arora
- Department of Orthopaedic Surgery, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, 110002, India
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McVeigh LG, Anokwute MC, Chen S, Jea A. Spinal column shortening for tethered cord syndrome: a systematic review and individual patient data meta-analysis. J Neurosurg Pediatr 2022; 29:624-633. [PMID: 35245903 DOI: 10.3171/2022.1.peds21503] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tethered cord release (TCR) is the gold standard treatment for tethered cord syndrome (TCS); however, there are significant shortcomings including high rates of retethering, especially in complex and recurrent cases. Spinal column shortening (SCS) is an alternative treatment for TCS intended to avoid these shortcomings. Early studies were limited to case reports and smaller case series; however, in recent years, larger case series and small cohort studies have been conducted. Given the increase in available data, a repeat systematic review and meta-analysis is warranted to assess the safety and efficacy of SCS for TCS. METHODS The authors conducted a systematic review using MEDLINE (OVID), Embase (Elsevier), and Web of Science records dating from 1944 to July 2021 to identify all articles investigating SCS for TCS. They performed standard and individual patient data (IPD) meta-analyses, with 2 independent reviewers using PRISMA-IPD guidelines. Primary outcomes were improvement of preoperative clinical symptoms of pain, motor weakness, and bladder and bowel dysfunction, and also surgical complication rate. Secondary outcomes included urodynamic improvement and health-related quality-of-life outcomes determined using patient-reported outcome tools. Individual study quality assessment was performed using a standardized assessment tool for case reports/series, and publication bias was assessed using funnel plot analyses. RESULTS The review yielded 15 studies with 191 cases of TCS treated with SCS. IPD were available in 11 studies with 89 cases. The average age at time of surgery was 28.0 years (range 5-76 years). The average follow-up time was 33.2 months (range 7-132 months). Improvement was observed at last follow-up in 60 of 70 (85.7%) patients with preoperative pain, in 38 of 60 (60.3%) patients with preoperative weakness, and in 36 of 76 (47.4%) patients with preoperative bladder or bowel dysfunction. Complications of CSF leak, new neurological deficit, wound infection, or reoperation occurred in 4 of 89 (4.5%) patients. CONCLUSIONS SCS may be considered a safe and efficacious treatment option for TCS in children and adults (level C evidence; class IIb recommendation), especially for recurrent and complex cases. Current evidence is likely to be affected by selection and publication bias. Prospective comparative studies of SCS and TCR for TCS are recommended to determine long-term duration of outcomes, long-term safety in skeletally immature children, and exact indications of SCS versus traditional TCR.
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Affiliation(s)
- Luke G McVeigh
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Miracle C Anokwute
- 1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sixia Chen
- 2Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Andrew Jea
- 3Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Kanno H, Aizawa T, Hashimoto K, Itoi E, Ozawa H. Anterior decompression through a posterior approach for thoracic myelopathy caused by ossification of the posterior longitudinal ligament: a novel concept in anterior decompression and technical notes with the preliminary outcomes. J Neurosurg Spine 2022; 36:276-286. [PMID: 34560660 DOI: 10.3171/2021.4.spine213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Various surgical procedures are used to manage thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL). However, the outcomes of surgery for thoracic OPLL are generally unfavorable in comparison to surgery for cervical OPLL. Previous studies have shown a significant risk of perioperative complications in surgery for thoracic OPLL. Thus, a safe and secure surgical method to ensure better neurological recovery with less perioperative complications is needed. The authors report a novel concept of anterior decompression through a posterior approach aimed at anterior shift of the OPLL during surgery rather than extirpation or size reduction of the OPLL. This surgical technique can securely achieve anterior shift of the OPLL using a curved drill, threadwire saw, and curved rongeur. The preliminary outcomes were investigated to evaluate the safety and efficacy of this technique. METHODS This study included 10 consecutive patients who underwent surgery for thoracic OPLL. Surgical outcomes, including the ambulatory status, Japanese Orthopaedic Association (JOA) score, and perioperative complications, were investigated retrospectively. In this surgery, pedicle screws are introduced at least three levels above and below the corresponding levels. The laminae, facet joints, transverse processes, and pedicles are then removed bilaterally at levels wherein subsequent anterior decompression is performed. For anterior decompression, the OPLL and posterior portion of the vertebral bodies are partially resected using a high-speed drill with a curved burr, enabling the removal of osseous tissues just ventral to the spinal cord without retracting the dural sac. To securely shift the OPLL anteriorly, the intact PLL and posterior portion of the vertebral bodies cranial and caudal to the lesion are completely resected using a threadwire saw and/or curved rongeur. Rods are connected to the screws, and bone grafting is performed for posterolateral fusion. RESULTS Five patients were nonambulatory before surgery, but all were able to walk at the final follow-up. The average JOA score before surgery and at the final follow-up was 3.2 and 8.8 points, respectively. Notably, the mean recovery rate of JOA score was 72%. Furthermore, no patients showed neurological deterioration postoperatively. CONCLUSIONS The surgical technique is a useful alternative for safely achieving sufficient anterior decompression through a posterior approach and may consequently reduce the risk of postoperative neurological deterioration and improve surgical outcomes in patients with thoracic OPLL.
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Affiliation(s)
- Haruo Kanno
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine; and
- 2Department of Orthopaedic Surgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Toshimi Aizawa
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine; and
| | - Ko Hashimoto
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine; and
| | - Eiji Itoi
- 1Department of Orthopaedic Surgery, Tohoku University School of Medicine; and
| | - Hiroshi Ozawa
- 2Department of Orthopaedic Surgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan
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Lee JY, Kim KH, Park K, Wang KC. Retethering : A Neurosurgical Viewpoint. J Korean Neurosurg Soc 2020; 63:346-357. [PMID: 32336063 PMCID: PMC7218204 DOI: 10.3340/jkns.2020.0039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 02/29/2020] [Indexed: 11/27/2022] Open
Abstract
During the follow-up period after surgery for spinal dysraphism, a certain portion of patients show neurological deterioration and its secondary phenomena, such as motor, sensory or sphincter changes, foot and spinal deformities, pain, and spasticity. These clinical manifestations are caused by tethering effects on the neural structures at the site of previous operation. The widespread recognition of retethering drew the attention of medical professionals of various specialties because of its incidence, which is not low when surveillance is adequate, and its progressive nature. This article reviews the literature on the incidence and timing of deterioration, predisposing factors for retethering, clinical manifestations, diagnosis, surgical treatment and its complications, clinical outcomes, prognostic factors after retethering surgery and preventive measures of retethering. Current practice and opinions of Seoul National University Children’s Hospital team were added in some parts. The literature shows a wide range of data regarding the incidence, rate and degree of surgical complications and long-term outcomes. The method of prevention is still one of the main topics of this entity. Although alternatives such as spinal column shortening were introduced, re-untethering by conventional surgical methods remains the current main management tool. Re-untethering surgery is a much more difficult task than primary untethering surgery. Updated publications include strong skepticism on re-untethering surgery in a certain group of patients, though it is from a minority of research groups. For all of the abovementioned reasons, new information and ideas on the early diagnosis, treatment and prevention of retethering are critically necessary in this era.
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Affiliation(s)
- Ji Yeoun Lee
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea.,Department of Anatomy, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Hyun Kim
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
| | - Kwanjin Park
- Division of Pediatric Urology, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyu-Chang Wang
- Division of Pediatric Neurosurgery, Seoul National University Children's Hospital, Seoul, Korea
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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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Aldave G, Hansen D, Hwang SW, Moreno A, Briceño V, Jea A. Spinal column shortening for tethered cord syndrome associated with myelomeningocele, lumbosacral lipoma, and lipomyelomeningocele in children and young adults. J Neurosurg Pediatr 2017; 19:703-710. [PMID: 28362188 DOI: 10.3171/2017.1.peds16533] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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 is the clinical manifestation of an abnormal stretch on the spinal cord, presumably causing mechanical injury, a compromised blood supply, and altered spinal cord metabolism. Tethered cord release is the standard treatment for tethered cord syndrome. However, direct untethering of the spinal cord carries potential risks, such as new neurological deficits from spinal cord injury, a CSF leak from opening the dura, and retethering of the spinal cord from normal scar formation after surgery. To avoid these risks, the authors applied spinal column shortening to children and transitional adults with primary and secondary tethered cord syndrome and report treatment outcomes. The authors' aim with this study was to determine the safety and efficacy of spinal column shortening for tethered cord syndrome by analyzing their experience with this surgical technique. METHODS The authors retrospectively reviewed the demographic and procedural data of children and young adults who had undergone spinal column shortening for primary or secondary tethered cord syndrome. RESULTS Seven patients with tethered cord syndrome caused by myelomeningocele, lipomyelomeningocele, and transitional spinal lipoma were treated with spinal column shortening. One patient with less than 24 months of follow-up was excluded from further analysis. There were 3 males and 4 females; the average age at the time was surgery was 16 years (range 8-30 years). Clinical presentations for our patients included pain (in 5 patients), weakness (in 4 patients), and bowel/bladder dysfunction (in 4 patients). Spinal column osteotomy was most commonly performed at the L-1 level, with fusion between T-12 and L-2 using a pedicle screw-rod construct. Pedicle subtraction osteotomy was performed in 6 patients, and vertebral column resection was performed in 1 patient. The average follow-up period was 31 months (range 26-37 months). Computed tomography-based radiographic outcomes showed solid fusion and no instrumentation failure in all cases by the most recent follow-up. Five of 7 patients (71%) reported improvement in preoperative symptoms during the follow-up period. The mean differences in initial and most recent Scoliosis Research Society Outcomes Questionnaire and Oswestry Disability Index scores were 0.26 and -13%, respectively; minimum clinically important difference in SRS-22 and ODI were assumed to be 0.4% and -12.8%, respectively. CONCLUSIONS Spinal column shortening seems to represent a safe and efficacious alternative to traditional untethering of the spinal cord for tethered cord syndrome.
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Affiliation(s)
- Guillermo Aldave
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Daniel Hansen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Steven W Hwang
- Shriners Hospitals for Children, Philadelphia, Pennsylvania; and
| | - Amee Moreno
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Valentina Briceño
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Andrew Jea
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.,Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurosurgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana
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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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Aizawa T, Kokubun S, Ozawa H, Kusakabe T, Tanaka Y, Hoshikawa T, Hashimoto K, Kanno H, Morozumi N, Koizumi Y, Sato T, Hyodo H, Kasama F, Ogawa S, Murakami E, Kawahara C, Yahata JI, Ishii Y, Itoi E. Increasing Incidence of Degenerative Spinal Diseases in Japan during 25 Years: The Registration System of Spinal Surgery in Tohoku University Spine Society. TOHOKU J EXP MED 2016; 238:153-63. [DOI: 10.1620/tjem.238.153] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai
| | - Shoichi Kokubun
- Department of Orthopaedic Surgery, NHO Sendai-Nishitaga Hospital
| | - Hiroshi Ozawa
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai
| | | | | | | | - Ko Hashimoto
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai
| | - Haruo Kanno
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai
| | - Naoki Morozumi
- Department of Orthopaedic Surgery, NHO Sendai-Nishitaga Hospital
| | - Yutaka Koizumi
- Department of Orthopaedic Surgery, NHO Sendai-Nishitaga Hospital
| | - Tetsuro Sato
- Department of Orthopaedic Surgery, Sendai Orthopaedic Hospital
| | - Hironori Hyodo
- Department of Orthopaedic Surgery, Sendai Orthopaedic Hospital
| | - Fumio Kasama
- Department of Orthopaedic Surgery, Matsuda Hospital
| | - Shinji Ogawa
- Department of Orthopaedic Surgery, Sendai Medical Center
| | | | | | | | - Yushin Ishii
- Department of Orthopaedic Surgery, NHO Sendai-Nishitaga Hospital
| | - Eiji Itoi
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai
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Safain MG, Burke SM, Riesenburger RI, Zerris V, Hwang SW. The effect of spinal osteotomies on spinal cord tension and dural buckling: a cadaveric study. J Neurosurg Spine 2015; 23:120-7. [PMID: 25884344 DOI: 10.3171/2014.11.spine14877] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The standard surgical release of a tethered cord may result in recurrent scar formation and occasionally be associated with retethering. The application of spinal shortening procedures to this challenging problem potentially can reduce tension on the retethered spinal cord while minimizing the difficulties inherent in traditional lumbosacral detethering revision. Although spinal shortening procedures have proven clinical benefit in patients with a recurrent tethered cord, it is unclear how much shortening is required to achieve adequate reduction in spinal cord tension or what impact these osteotomies have on dural buckling. METHODS The authors calculated mean values from 4 human cadavers to evaluate the effect of 3 different spinal shortening procedures--Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR)--on spinal cord tension and dural buckling. Three cadavers were dedicated to the measurement of spinal cord tension, and 3 other cadavers were devoted to myelography to measure dural buckling parameters. RESULTS The SPO was associated with a maximal decrease in spinal cord tension of 16.1% from baseline and no dural buckling with any degree of closure. The PSO led to a mean maximal decrease in spinal cord tension of 63.1% from baseline at 12 mm of closure and demonstrated a direct linear relationship between dural buckling and increasing osteotomy closure. Finally, VCR closure correlated with a mean maximal decrease in spinal cord tension of 87.2% from baseline at 10 mm of closure and also showed a direct linear relationship between dural buckling and increases in osteotomy closure. CONCLUSIONS In this cadaveric experiment, the SPO did not lead to appreciable tension reduction, while a substantial response was seen with both the PSO and VCR. The rate of tension reduction may be steeper for the VCR than the PSO. Adequate tension relief while minimizing dural buckling may be optimal with 12-16 mm of posterior osteotomy closure based on this cadaveric experiment.
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Affiliation(s)
- Mina G Safain
- Department of Neurosurgery, Tufts Medical Center;,Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts; and
| | - Shane M Burke
- Department of Neurosurgery, Tufts Medical Center;,Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts; and
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center;,Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts; and
| | | | - Steven W Hwang
- Department of Neurosurgery, Tufts Medical Center;,Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts; and
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Tao HR, Yang TL, Chang MS, Li H, Zhang DW, Fan HB, Shen C, Luo ZJ. Successful treatment of a patient with congenital kyphoscoliosis associated with tethered cord. J Neurosurg Spine 2014; 22:64-9. [PMID: 25343408 DOI: 10.3171/2014.9.spine13528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Tethered cord is a common finding in congenital scoliosis. The most frequently advocated approach for this condition is to perform prophylactic detethering of the cord before scoliosis corrective surgery. The authors report on a 14-year-old patient with congenital thoracic kyphoscoliosis associated with a tethered cord, who developed progressive paraparesis and was successfully treated by posterior spine shortening osteotomy alone without prophylactic untethering. The patient had a 103° scoliotic curve together with a 93° kyphotic curve with an apical vertebra of T-7. Furthermore, he developed a significant progression of neurological deficits, including weakness of both legs and urinary and bowel incontinence. Preoperative MRI revealed that the spinal cord was entrapped by the apical vertebra and the low-placed conus medullaris was at approximately L-5. A posterior vertebral column resection of T-7 was performed for the purpose of simultaneously correcting the kyphoscoliosis and releasing tension on the tethered cord without a true detethering surgery. The patient's spinal cord function recovered completely from Frankel D to Frankel E by 6 months after the procedure. Evaluation at 31 months after surgery showed maintenance of good curve correction and normal neurological function.
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The risk factors of neurologic deficits of one-stage posterior vertebral column resection for patients with severe and rigid spinal deformities. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2013; 23:149-56. [PMID: 23619771 DOI: 10.1007/s00586-013-2793-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 12/29/2012] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine the risk factors of neurologic deficits during PVCR correction, so as to help improve safety during and after surgery. METHODS A consecutive series of 76 patients with severe and rigid spinal deformities who were treated with PVCR at a single institution between October 2004 and July 2011 were included in our study. Of the 76 patients, 37 were male and 39 female, with an average age of 17.5 years (range 10-48 years). There were 52 adolescent patients (with an age <18 years) and 24 adult patients (with an age ≥18 years). Preoperatively, postoperatively and 6 months after surgery, we performed systemically neurologic function evaluations of each patients through meticulous physical examination. Any new abnormality or deterioration in evaluation of neurologic function than preoperative is reckoned postoperative neurologic deficits. Ten variables that might affect the safety of neurologic deficits during PVCR procedures, including imaging factors, clinical factors and operational factors, were analyzed using univariate analysis. Then the variables with statistical difference were analyzed by using multi-factor unconditional logistic regression analysis. RESULTS No patient in this series had permanent paraplegia and nerve root injury due to operation. Change of neurologic status was found in six patients after surgery. Results of single-factor comparison demonstrated that the following seven variables were statistically different (P < 0.05): location of apex at main curve (X 3), Cobb angle at the main curve at the coronal plane (X 4), scoliosis associated with thoracic hyperkyphosis (X 5), level of vertebral column resected (X 6), number of segmental vessels ligated (X 7), preexisting neurologic dysfunction (X 8), and associated with intraspinal and brain stem anomalies (X 9). The multi-factor unconditional logistic regression analysis revealed that X 8 (OR = 49.322), X 9 (OR = 18.423), X 5 (OR = 11.883), and X 6 (OR = 8.769) were independent and positively correlated with the neurologic deficit. CONCLUSIONS Preexisting neurologic dysfunction, associated with intraspinal and brain stem anomalies, scoliosis associated with thoracic hyperkyphosis and level of vertebral column resected are independent risk factors for neurologic deficits during PVCR procedure.
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Chen ZW, Ding ZQ, Zhai WL, Lian KJ, Kang LQ, Guo LX, Liu H, Lin B. Anterior versus posterior approach in the treatment of chronic thoracolumbar fractures. Orthopedics 2012; 35:e219-24. [PMID: 22310410 DOI: 10.3928/01477447-20120123-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare the results of anterior approach vs posterior approach in the treatment of chronic thoracolumbar fractures. A total of 36 patients with chronic thoracolumbar fractures were divided into 2 groups. Group A was treated by an anterior approach and group B was treated by a posterior approach. During the minimum 24-month follow-up period (range, 24-62 months), all patients were prospectively evaluated for clinical and radiologic outcomes. Intraoperative blood loss, operative time, operative complications, pulmonary function, Frankel scale, and American Spinal Injury Association (ASIA) motor score were used for clinical evaluation, and Cobb angle was examined for radiologic outcome. All patients in this study achieved solid fusion, with significant neurologic improvement. Operative time, perioperative blood loss, ASIA score on admission and at final follow-up, and complications of respiratory tract infection and intercostal nerve pain were not significantly different between the 2 groups (P>.05), but complications of hemopneumothorax, abdominal distension, and constipation were fewer in group B (P<.05). Postoperative pulmonary function (P<.05) and correction of posttraumatic kyphosis were better in group B (P<.05).
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Affiliation(s)
- Zhi-wen Chen
- Department of Orthopaedics, 175th Hospital of PLA, Traumatic Orthopaedics Center of PLA, Southeast Hospital of Xiamen University, Zhangzhou, Fujian Province, PR China
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Traynelis VC. Editorial: Spine shortening of tethered cord. J Neurosurg Spine 2011; 15:19-20; author reply p 20. [DOI: 10.3171/2010.12.spine10725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kokubun S, Ozawa H, Aizawa T, Ly NM, Tanaka Y. Spine-shortening osteotomy for patients with tethered cord syndrome caused by lipomyelomeningocele. J Neurosurg Spine 2011; 15:21-7. [PMID: 21495816 DOI: 10.3171/2011.2.spine10114] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tethered cord syndrome (TCS) is a disorder involving an abnormal stretching of the tethered spinal cord caused by several pathological conditions and presents with a variety of neurological symptoms. Untethering (tethered cord release) is the gold standard treatment for TCS. However, untethering carries risks of spinal cord injury and postoperative retethering. To avoid these potential risks, the authors applied spine-shortening osteotomy to adult patients with TCS, and report on the surgical procedure and treatment outcomes. METHODS Eight patients with TCS caused by a lipomyelomeningocele were surgically treated by the authors' original procedure of spine-shortening osteotomy. Six patients were male and 2 were females; average age at the time of surgery was 31 years old. Spine-shortening osteotomy was performed at the level of L-1 in all but 2 patients, in whom it was performed at T-12, with spinal fusion between T-12 and L-2 or T-11 and L-1 using a pedicle screw-rod system. The average follow-up period was 6.2 years and the patients' pre- and postoperative conditions were evaluated clinically and radiologically. RESULTS Preoperatively, all patients displayed severe neurological deficits such as motor disturbance, muscle atrophy, and bladder dysfunction. Several months before surgery, all showed progressive symptoms. Those symptoms showed initial improvement in 6 patients and stabilized in 2 postoperatively, but the improved symptoms worsened again in 4 of the 6 patients. The osteotomized vertebrae were shortened by 21 mm on average, and all spines showed complete bone union without loss of correction. At the final follow-up evaluations, 6 patients showed stabilization as per the modified Japanese Orthopaedic Association score for thoracic myelopathy. CONCLUSIONS Spine-shortening osteotomy successfully helps reduce the spinal cord tension without causing direct neural damage. At minimum, it stabilized the patients' symptoms and/or helped delay neurological deterioration for a period of time. Spine-shortening osteotomy might be a feasible mode of treatment for adult TCS caused by a spinal lipoma.
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Affiliation(s)
- Shoichi Kokubun
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, Sendai, Japan
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Hsieh PC, Stapleton CJ, Moldavskiy P, Koski TR, Ondra SL, Gokaslan ZL, Kuntz C. Posterior vertebral column subtraction osteotomy for the treatment of tethered cord syndrome: review of the literature and clinical outcomes of all cases reported to date. Neurosurg Focus 2010; 29:E6. [DOI: 10.3171/2010.4.focus1070] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Tethered cord syndrome (TCS) is a debilitating condition of progressive neurological decline caused by pathological, longitudinal traction on the spinal cord. Surgical detethering of the involved neural structures is the classic method of treatment for lumbosacral TCS, although symptomatic retethering has been reported in 5%–50% of patients following initial release. Subsequent operations in patients with complex lumbosacral dysraphic lesions are fraught with difficulty, and improvements in neurological function are modest while the risk of complications is high. In 1995, Kokubun described an alternative spine-shortening procedure for the management of TCS. Conducted via a single posterior approach, the operation relies on spinal column shortening to relieve indirectly the tension placed on the tethered neural elements. In a cadaveric model of TCS, Grande and colleagues further demonstrated that a 15–25-mm thoracolumbar subtraction osteotomy effectively reduces spinal cord, lumbosacral nerve root, and filum terminale tension. Despite its theoretical appeal, only 18 reports of the use of posterior vertebral column subtraction osteotomy for TCS treatment have been published since its original description. In this review, the authors analyze the relevant clinical characteristics, operative data, and postoperative outcomes of all 18 reported cases and review the role of posterior vertebral column subtraction osteotomy in the surgical management of primary and recurrent TCS.
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Affiliation(s)
- Patrick C. Hsieh
- 1Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Christopher J. Stapleton
- 1Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
- 2Harvard–M.I.T. Division of Health Sciences and Technology, Harvard Medical School, Boston, Massachusetts
| | - Pavel Moldavskiy
- 1Department of Neurological Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Tyler R. Koski
- 3Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stephen L. Ondra
- 3Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ziya L. Gokaslan
- 4Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Charles Kuntz
- 5Department of Neurosurgery, Mayfield Clinic and Spine Institute, University of Cincinnati, Ohio
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Progressive kyphoscoliosis associated with tethered cord treated by posterior vertebral column resection: a case report. Spine (Phila Pa 1976) 2009; 34:E965-8. [PMID: 20010386 DOI: 10.1097/brs.0b013e3181af7a6a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN.: A case report. OBJECTIVES.: To report a case of progressive kyphoscoliosis associated with a tethered cord that was corrected by posterior vertebral column resection after complicated untethering surgery. SUMMARY OF BACKGROUND DATA.: There have been few clinical reports on posterior vertebral column resection conducted for severe deformity associated with a tethered cord. METHODS.: A patient with progressive kyphoscoliosis associated with a tethered cord first underwent untethering surgery, resulting in neurologic deterioration. Posterior vertebral column resection was performed to correct the kyphoscoliosis while shortening the spinal column to prevent the spinal cord from stretch injury. RESULTS.: Good correction of kyphoscoliosis was obtained without further neurologic deterioration. The Cobb angles of scoliosis was 103 degrees before surgery and 25 degrees after surgery (correction rate; 75.7%), and that of kyphosis was 90 degrees and 36 degrees , respectively (correction rate; 60.0%). CONCLUSION.: Correction of progressive kyphoscoliosis associated with a tethered cord can be achieved successfully by posterior vertebral column resection even after complicated untethering surgery.
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Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE To review findings from 3 patients who underwent spine-shortening vertebral osteotomy for tethered cord syndrome with a minimum follow-up of 3 years. SUMMARY OF BACKGROUND DATA Surgical detethering is the gold standard for symptomatic tethered cord syndrome. However, complications such as cerebrospinal fluid leakage and neurologic deterioration are common. Spine-shortening vertebral osteotomy, proposed by Kokubun, is an alternative surgical technique to reduce neural tension indirectly. However, case series of this novel procedure for tethered cord syndrome have not been reported in the English literature. METHODS Three patients aged 13, 22, and 27 years presented with progressive pain and/or neurologic dysfunction. They underwent spine-shortening vertebral osteotomy of L1 with a pedicle screw and rod system. Their clinical and radiologic outcomes are reviewed. RESULTS All patients got relief from their preoperative symptoms after surgery, and no complications occurred. Complete bone union was obtained in all patients without correction loss. CONCLUSION Spine-shortening vertebral osteotomy can be a safe and alternative surgical technique for tethered cord syndrome.
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Fehlings MG, Arvin B. Recurrent tethered cord syndrome: a novel approach for a difficult surgical condition? J Neurosurg Spine 2009; 10:275-6; author reply 276-7. [PMID: 19441982 DOI: 10.3171/2008.12.spine08835] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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