Tethered Cord Syndrome Research Articles

Growth profile assessment of young adults with tethered cord syndrome: a retrospective cohort analysis of Korean conscription data.

Tethered cord syndrome (TCS) is characterized by progressive spinal cord degeneration secondary to congenital spinal dysraphism. The associated accompanying physical inactivity and musculoskeletal deformities have raised interest in the growth profile of adult TCS patients. However, few previous studies have investigated the growth profile of adult TCS patients. We retrospectively reviewed the demographic data and medical records of 20-year-old Korean conscription examinees who were registered between April 2004 and September 2019. In total, 151 examinees with a diagnosis of TCS were enrolled. The height, weight, and body mass index (BMI) of 300 randomly selected examinees were compared to the TCS group. Obesity was defined by the World Health Organization and Asian-Pacific criteria for BMI and compared between the groups. Growth profile differences according to tethering location and musculoskeletal deformities were analyzed in both groups. The mean height, weight, and BMI values of the TCS group were lower than those of the control group. The TCS group had a lower proportion of obese and overweight individuals, and a higher proportion of underweight individuals, according to both BMI criteria. The tethering level was not associated with the degree of obesity in the tethered group. The mean height, weight, and BMI were lower in the tethered group regardless of the existence of musculoskeletal deformity. Enrollees with a history of TCS were smaller than controls of the same age. Monitoring of health behaviors, including nutrition, diet, and exercise, is warranted for TCS patients.

Risk of occult spinal dysraphism based on lumbosacral cutaneous manifestations.

Objectives:Occult spinal dysraphism is a congenital failure of fusion of the posterior vertebral arches with intact skin overlying the defect. Lumbosacral cutaneous manifestations are associated with a variable risk of occult spinal dysraphism. Tethered cord syndrome is a type of occult spinal dysraphism that puts abnormal traction on the spinal cord. This study analyzed neonates and infants who were referred to our pediatric urology practice and had evidence of lumbosacral cutaneous manifestation on physical examination.Methods:We reviewed the presence of lumbosacral cutaneous manifestations in neonates and infants evaluated in our pediatric urology clinic at our Institution over a 6-year period (1 March, 2015–28 February, 2021) with no prior diagnosis of lumbosacral cutaneous manifestation. All patients underwent a spinal ultrasound.Results:The most common lumbosacral cutaneous manifestations were bifurcated/duplicated gluteal folds (33%), gluteal asymmetry (19%), and sacral dimples (14%). A total of 34 (24%) patients had an abnormal spinal ultrasound; 15 (44%) of these infants underwent a lumbar magnetic resonance imaging. A coccygeal pit was statistically marginally higher in abnormal versus normal spinal ultrasound (p = 0.07). Patients with only one lumbosacral cutaneous manifestation (N = 121) were significantly more likely to have a normal spinal ultrasound compared to those with two or more lumbosacral cutaneous manifestation (N = 17) (79% vs 53%, p = 0.03).Conclusion:Due to the varying risk of certain lumbosacral cutaneous manifestations with occult spinal dysraphism, all patients with a lumbosacral cutaneous manifestation should undergo spinal ultrasound. This study also highlights the importance of urodynamic studies when there are abnormal cutaneous findings. Routine physical examinations of the lumbar region for cutaneous manifestations of occult spinal dysraphism are vital to ensure prompt management of tethered cord syndrome and avoid potentially devastating consequences.

Features of the Filum Terminale in Tethered Cord Syndrome with Focus on Pathology.

ObjectiveFilum transection is one of the most commonly performed operative procedure in pediatric neurosurgery. However, the clinical and pathological features as well as the surgical indication are not well-established. This study aimed to analyze the characteristics of patients who underwent transection of the filum during the last 10 years in a single institute. MethodsA total of 82 patients underwent transection of the filum during the period. As a general rule, we performed the transection in patients who are symptomatic or have abnormality in the urologic or neuromuscular evaluations. There were exceptions as asymptomatic patients who only fit the definition of thickened filum (width greater than 2.0 mm or conus level below L3 vertebral body) were operated by parent’s wish or surgeon’s preference according to radiological findings, etc. ResultsSeventy-six out of 82 patients had fibrous tissue in the pathologic specimen of filum. Interestingly, patients who had glial cells were more correlated with no preoperative syrinx, and no progression of syrinx even for those who did have syrinx initially. Also, larger percentage of symptomatic patients had peripheral nerve twigs than asymptomatic patients. No difference in conus level or thickness of filum was found between patients with or without preoperative syrinx. Significantly more patients with syrinx (56%) were chosen to be operated without any symptom or abnormality in study i.e., solely based on radiological findings than those without syrinx (21%). The surgical outcome for syrinx was favorable, as all but one patient had either improved or static syrinx. The exceptional case had increase in size due to the upward displacement of the proximal end of the cut filum. ConclusionThis study evaluated the pathological, clinical, radiological features of patients who underwent transection of the filum. Interesting correlations between pathological findings and clinical features were found. Excellent outcome regarding preoperative syrinx was also shown.

Neurosurgery guidelines for the care of people with spina bifida

Myelomeningocele (MMC) arises from an early neural developmental anomaly and results in a variety of structural abnormalities and associated functional neurologic deficits. As such, neurologic issues are central to virtually all clinical problems. Neurosurgical intervention strives to correct or improve these defects and prevent secondary complications. These interventions include closure of the open myelomeningocele and management (across the life span) of hydrocephalus, the Chiari II malformation (C2M) and tethered spinal cord (TSC). The development of pre-natal closure techniques and reports of improved outcome with in-utero closure (IUMC) have revolutionized the neurosurgical approach to myelomeningocele. Controversies remain surrounding patient selection, maternal risks, technique of IUMC (endoscopic vs. open) and long-term outcomes. However, real gains include reduced rates of hydrocephalus, modestly improved motor capabilities and reduction in C2M morbidity. For many decades, the cornerstone of treatment of hydrocephalus for many decades has been the placement and support of ventricular shunts. Endoscopic third ventriculostomy (ETV) with or without choroid plexus coagulation (ETV/CPC) is an appealing alternate strategy that avoids the morbidity and complications associated with shunts. The exact criteria for ETV-CPC candidacy and best metrics for outcome analysis remain active areas of debate and controversy. Similarly, neurosurgical management C2M, has centered upon the indications and clinical thresholds for performing posterior fossa surgical decompression. Tethered spinal cord management incorporates the diagnosis and surgical management of adhesions formed at the initial closure site, the consequent longitudinal traction related stress on the cord and the resulting neurologic signs and symptoms.

MRI characteristics of the fetal tethered spinal cord: a comparative study

Purpose: To compare fetuses and children with confirmed tethered cord syndrome to age-matched controls to provide a reference for prenatally identifying tethered spinal cord and to identify salient points on MRI for diagnosis. Materials and Methods: This retrospective study enrolled 13 fetuses and 20 children with tethered cord syndrome, and age-matched counterparts were included as controls. The MRI features including concomitant malformations, position of the conus medullaris, and thickened filum terminale of the two patient groups were evaluated and compared. Levels of the conus medullaris were discriminated between patients and an equivalent number of controls. Results: Various concomitant malformations manifested on the MRI of all patients, and there were differences between the two patient groups. Significant differences of the level of the conus medullaris were found between the fetal and child patients (U, 26.50; Z, −3.87; p < 0.001) and between the normal fetus and child controls (U, 23.50; Z, −4.13; p < 0.001). The position of the conus medullaris was visibly lower in the patient groups than in the control groups. No significant difference in the diameters of the filum terminale was found between the fetal and child patients (p = 0.67). Conclusions: The current study’s results indicate that tethered spinal cord syndrome can be diagnosed in utero with MRI combined with several characteristics, particularly the position of the conus medullaris. Special attention should be paid to the gestational age of the fetus because normal changes in spinal cord position occur with gestational development.

Analysis of the efficacy of the Ponseti method for treatment of secondary clubfoot in young children with tethered cord syndrome

Objective: To explore the feasibility of Ponseti method in treatment of secondary clubfoot in young children with Tethered Cord Syndrome(TCS). Methods: The clinical data of 53 young children with clubfeet treated with Ponseti method from March 2014 to March 2017 at Department of Pediatric Orthopedics, the Third Affiliated Hospital of Zhengzhou University were analyzed retrospectively. These patients were divided into TCS group and Idiopathic group according to the etiology. There were 19 patients (33 feet) in TCS group,with an mean age of 2.8 months(range:0.2 to 24.0 months), including 13 males and 6 females, 5 patients with unilateral clubfeet and 14 patients with bilateral clubfeet. There were 34 patients (45 feet) in idiopathic group, with an mean age of 3.1 months(range: 0.1 to 21.0 months), including 18 males and 16 females, 23 patients with unilateral clubfeet and 11 patients with bilateral clubfeet. All the children received casts correction according to Ponseti method, and were followed up at 3 weeks, 3 months, 6 months and every 6 months after the Achilles tendon tenotomy or the last cast correction. Complications were recorded and therapeutic effect was evaluated of these children by Dimeglio Scoring System and the International Clubfoot Study Group (ICFSG) at the last follow-up. Independent t test, Mann-Witney U test or χ(2) test were used to compare the indicators of the two groups. Results: The number of plaster fixation in TCS group was (6.1±2.0) times, and that of idiopathic group was (4.8±1.0) times(t=3.482, P<0.01).In TCS group, 22 feet treated with Achilles tendon transection and that of idiopathic group was 40 feet(χ(2)=0.279, P=0.598). There were 18 cases recurrence in TCS group and 8 cases in Idiopathic group (t=11.149, P<0.01). In TCS group, 16 cases (27 feet) completed the initial correction, the success rate was 60.6% (27/33), 3 cases (6 feet) could not correct the deformity after 9 to 10 times of plaster fixation, and then underwent soft tissue release.In idiopathic group, 34 cases (45 feet) achieved initial correction after Ponseti treatment(χ(2)=6.488, P=0.011).At the last follow up, there were 5 cases (9 feet) in TCS group and 2 cases (2 feet) in idiopathic group underwent soft tissue release(χ(2)=6.110, P=0.013). The classification grade of ICFSG score of the two groups without soft tissue release were (2.1±0.6) and (1.8±0.7), the difference was not statistically significant (t=1.765, P=0.082). All the children had no skin ulceration, bedsores, skin allergy and other complications. Conclusion: Ponseti method is effective in the treatment of clubfoot secondary to TCS, and the functional recovery is similar to that of children with idiopathic clubfoot.

Filum Terminale Lipoma with Herniated Intervertebral Disc Treated with Traditional Korean Medicine: A Case Report

Filum terminale lipoma is an inherited lumbosacral abnormality that can cause tethered cord syndrome. This report describes an unusual case of lumbago and sciatica, pain suspected to be caused by a filum terminale lipoma where a herniated intervertebral disc had occurred. The patient was hospitalized for 43 days and received integrative Korean medicine treatment, including acupuncture, pharmacopuncture, Chuna therapy, cupping therapy, physiotherapy and herbal medicine. Treatment effectiveness was assessed using the numerical rating scale, Oswestry Disability Index, European Quality of Life 5-Dimensions, and patient symptoms. After inpatient treatment, the pain the patient suffered was significantly reduced, and the evaluation indices scores reflected this. Integrative Korean remedies may be an effective option for lower back pain and lower extremity symptoms which are caused by filum terminale lipoma where a herniated intervertebral disc has occurred. Additional clinical research is required to support this observation.

Split cord malformation and tethered cord syndrome: case series with long-term follow-up and literature review.

To date, the description of the natural course of concurrent tethered cord syndrome with a low-lying conus medullaris and split cord malformation is lacking in the literature. We report a cohort of adult and pediatric patients with concurrent malformations and long-term follow-up. Patients with concurrent diagnoses of split cord malformation and tethered cord (radiographic evidence supporting clinical symptomatology) were identified between 2000 and 2020. Patients without sufficient documentation or at least 6-month follow-up were excluded. Nine patients were identified with an average of 8.9 years follow-up (range 2-31 years). The most common symptoms were radiating leg pain and lower extremity paresthesias, occurring in 44% of patients; and bladder/bowel dysfunction, worsening scoliosis, and acute motor deterioration were less common. Two patients were successfully treated conservatively for mild leg pain and paresthesias. For those who underwent surgery, all experienced symptomatic relief upon first follow-up. Two had late symptomatic recurrence; one 4 and 8 years after initial surgery; and the other, 11, 26, and 31 years after initial surgery. The rarity of concurrent split cord and tethered cord syndrome with a low-lying conus makes management difficult to formulate. This series supplements our knowledge of the long-term outcomes and lessons learned from the management of these patients. Approximately 25% of patients were managed conservatively and had symptomatic improvement. For surgically managed patients, with intractable pain or worsening neurological function, symptoms can still recur over a decade after intervention. Reoperation, however, can still be beneficial, can provide years of relief, and should be considered.

Is detethering necessary before deformity correction in congenital scoliosis associated with tethered cord syndrome: a meta-analysis of current evidence

To compare the clinical and radiological outcomes in patients with congenital scoliosis (CS) and tethered cord syndrome (TCS) undergoing deformity correction with (NI group) versus without (NNI group) prior neurosurgical intervention aimed at detethering the cord. A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until March 2020. Inclusion criteria was studied describing performance of deformity correction and fusion surgery for congenital scoliosis with tethered cord syndrome with or without prior detethering procedure. Studies describing growth sparing procedures or congenital scoliosis associated with non-tethering pathologies such as syrinx were excluded. Case reports and series with less than 10 subjects were also excluded. NIH quality assessment tool was used for assessing quality of individual study. Sixteen studies were included for analysis of which eight were found to be retrospective case series (level IV evidence) and retrospective case–control studies (level III evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, operative duration, blood loss or complication rate between the NI and NNI groups. However, subgroup analysis performed after inclusion of only level III evidence studies revealed significantly lesser operative duration and blood loss with comparable correction and complication rate in NNI group. Deformity correction and fusion surgery may be performed safely and effectively in CS with TCS patients without the need of a prior detethering procedure.

Tethered Cord Syndrome After Myelomeningocele Repair: A Literature Update.

Tethered cord syndrome (TCS) after myelomeningocele (MMC) repair (or secondary TCS) is a challenging condition characterized by neurological, orthopedic, and urological symptoms, which are combined with a low-lying position of the conus medullaris and damage to the stretched spinal cord owing to metabolic and vascular derangements. It has been reported that this syndrome affects, on average, 30% of children with MMC. In this review, we revisit the historical aspects of secondary TCS and highlight the most important concepts of diagnosis, treatment, and outcomes for secondary TCS as well as the current research regarding the impact of fetal MMC repair in the incidence and management of TCS. In the future, the development of synthetic models of TCS could shorten the learning curve of pediatric neurosurgeons, and research into the cellular proapoptotic features and increased inflammation biomarkers associated with TCS will also improve the treatment of this condition and minimize retethering of the spinal cord.

Anesthetic management of cesarean section of a wheelchair bound parturient with myelomeningocele

Neural tube defects (NTD) affect 1-2 in 1000 pregnancies over the world. The most frequent spinal dysraphisms are meningocele and myelomeningocele while the spina bifida occulta, tethered cord, lipomyelomeningocele, split cord malformations, neuroenteric cyst, and several other conditions occur less frequently. Open spinal dysraphisms (meningocele and myelomeningocele) are compatible with postnatal survival, but they can result in severe neurologic impairment as inability to ambulate, urinary incontinence, hydrocephalus, scoliosis, and gastrointestinal (GI) disorders. Closed spinal dysraphisms (spina bifida occulta, tethered cord, lipomyelomeningocele, split cord malformations, neuroenteric cyst) are often less severe and sometimes asymptomatic but may result in severe neurologic impairment secondary to spinal cord tethering. Modern health care facilities has resulted in a significant decrease in the mortality rate in patients with SB2 along with improved survival rate up to 80%. Due to the neurologic complexity and severity of these conditions, it is paramount to understand the challenges and offer the best anesthetic approach for these patients. To the best of our knowledge, this is the first case of SB going under caesarean delivery in our hospital. We wish to highlight our experience of perioperative management of this patient.&#x0D; Key words: Spina bifida, anesthetic management&#x0D; Citation: Lal S, Aisa T, Akram U, Sher A, Memon Z, Moriarty RM. Anesthetic management of cesarean section of a wheelchair bound parturient with myelomeningocele. Anaesth. pain intensive care 2020;24(5):&#x0D; Received: 13 June 2020, Reviewed: 24 June 2020, Revised: 18 July 2020, Accepted: 8 August 2020

Multidisciplinary Management of Tethered Spinal Cord Syndrome in Children: Operationalizing an Outpatient Patient-Centered Workflow.

IntroductionMultidisciplinary care for patients with tethered spinal cord syndrome (TCS) is valuable in ensuring comprehensive evaluation, timely follow-up, optimal functional outcome, and patient-centered care. The family-centered focus aims to minimize patient and parental burdens associated with care coordination. We present our first-year institutional experience in operationalizing a multidisciplinary, patient-centered, pediatric tethered cord clinic (TCC) to manage routine, long-term surgical follow-up for children with non-myelomeningocele-related tethered spinal cords.MethodsTCC is composed of three surgical services: orthopedic surgery, neurosurgery, urology. A retrospective chart review of patients seen in the TCC from January 2019 to January 2020 was conducted. Patients enrolled in the clinic were intended for long-term follow-up. Demographic and outcome variables were collected.ResultsFifty-nine patients were seen in TCC. Types of tethered spinal cords amongst these patients were the following: fatty filum (62.7%), dermal sinus tract (15.2%), meningocele manqué (8.4%), lipomyelomeningocele (6.7%), low lying conus medullaris (5.1%), and sacral arachnoid cyst (1.7%). Age at diagnosis was 1.31 ± 2.21 (median: 0.25 years) and at follow-up was 9.0 ± 5.18 years (median: 8 years). A total of 50.9% of patients were female, and 93.2% had a prior untethering procedure. Of all patients, 6.8% have no surgical intervention and continue to be monitored conservatively for evidence of decline. All three services evaluated 84.8% of patients during the same clinic session, while 15.3% of patients were seen by two of the services, and 20.3% of patients were able to schedule related imaging or diagnostic testing during the same visit.ConclusionWe describe successful implementation of a multidisciplinary pediatric TCC and document the first year of experience. The TCC streamlines care, decreases burden on families, and reduces those lost to follow-up. Complex disease pathologies, even when clinically stable, require long-term follow-up with multiple subspecialties and benefit from multidisciplinary clinics.

Intraoperative Neurophysiology Monitoring for Spinal Dysraphism

Spinal dysraphism often causes neurological impairment from direct involvement of lesions or from cord tethering. The conus medullaris and lumbosacral roots are most vulnerable. Surgical intervention such as untethering surgery is indicated to minimize or prevent further neurological deficits. Because untethering surgery itself imposes risk of neural injury, intraoperative neurophysiological monitoring (IONM) is indicated to help surgeons to be guided during surgery and to improve functional outcome. Monitoring of electromyography (EMG), motor evoked potential, and bulbocavernosus reflex (BCR) is essential modalities in IONM for untethering. Sensory evoked potential can be also employed to further interpretation. In specific, free-running EMG and triggered EMG is of most utility to identify lumbosacral roots within the field of surgery and filum terminale or non-functioning cord can be also confirmed by absence of responses at higher intensity of stimulation. The sacral nervous system should be vigilantly monitored as pathophysiology of tethered cord syndrome affects the sacral function most and earliest. BCR monitoring can be readily applicable for sacral monitoring and has been shown to be useful for prediction of postoperative sacral dysfunction. Further research is guaranteed because current IONM methodology in spinal dysraphism is still deficient of quantitative and objective evaluation and fails to directly measure the sacral autonomic nervous system.

Spinal Cord Stimulation inpatient with Tethered Cord syndrome: A Case Report

Background: Neuromodulation techniques are an important part of the chronic refractory neuropathic pain treatment. Their effectiveness is insufficiently documented in patients with tethered cord syndrome. Case Description: We present the case of a 32-year-old woman with a history of myelomeningocele repair, followed by a detethering surgery complicated with cerebral fluid leakage. Her intractable pain in her left leg and low back was successfully treated with spinal cord stimulation. Pain intensity decreased from 8/10 to 1-2/10 on her visual analogue scale without regular analgesic intake and her quality of life improved significantly. Conclusions: A review of the literature documents only three case reports of similar efficacy of spinal cord stimulation in the treatment of pain in adult patients with tethered cord syndrome.

Utility of CISS imaging in the management of tethered cord syndrome

To compare the utility of constructive interference in steady-state (CISS) sequence over T2-weighted (T2W) sequence in the accurate delineation of the tethering element on magnetic resonance (MR) imaging in patients of tethered cord syndrome (TCS) and correlation with intraoperative findings. MR findings of fifty-six consecutive patients with operative findings of TCS were studied. The intraoperative findings of all patients were studied and compared with the preoperative imaging findings on T2W imaging and CISS images. CISS images provided more information than T2W imaging. The overall sensitivity of CISS in MR evaluation of patients with TCS was higher (99.17%) as compared with the T2W sequence (71.48%) especially in the detection of precise position/extent of tethered cord, assessment of filum terminale thickening, detection of a fibrous spur in cases of split cord malformation, detection of dorsal dermal sinus, and evaluation of its precise extent and ramifications. The area under the ROC curve was higher with CISS (0.99) than with T2W sequence (0.85) which reflects its good predictive value as a screening test. This information was useful to the operating surgeon. CISS sequence for imaging TCS can help enhance the overall surgical outcome of the patients ensuring completeness of the surgery. CISS should be routinely performed in the work-up of patients with tethered cord syndrome.

Filum terminale lipomas-the role of intraoperative neuromonitoring.

Filum terminale lipomas (FTL) represent a sub-type of spinal lipomas, where there is fatty infiltration of the filum. It becomes a surgical entity when it manifests as clinical or radiological tethered cord syndrome. Intraoperative neuromonitoring (IONM) has been suggested as a valuable tool in children for tethered cord surgeries. FTL is distinct and cannot be compared with complex tethered cord syndrome (TCS). Untethering an FTL is a relatively straightforward microsurgical exercise, usually based on anatomical findings. Neurological morbidity in FTL untethering is extremely low. The necessity of IONM in FTL has not been evaluated. The objective of this study was to identify the role of IONM in untethering an FTL METHODS: Available electronic data and case files were interrogated to identify children (0-18 years) who underwent an untethering of FTL between 2008 and 2019. We had a shift in our policy and tried to use IONM as often as possible in all tethered cord surgery from 2014. All children were categorised under 'IONM implemented' or 'no IONM' group. Outcomes analysed were as follows: (1) Clinical status on short-term and long-term follow-up, (2) alteration of surgical course by IONM and (3) complications specifically associated with IONM RESULTS: Among 80 children included in this study, IONM was implemented in 37 children and 43 children underwent untethering without IONM. 32.5% of children were 'syndromic'. Seventy-five percent of children were under age 3 years during surgery. Both groups (No IONM vs. IONM implemented) were well matched in most variables. Majority of 'no IONM' surgeries were performed prior to 2014. There was no neurological morbidity in the entire cohort. Mean duration of follow-up was 49.10 (± 33.67) months. Short-term and long-term clinical status remained stable in both cohorts. In 16 children, the filum was stimulated. Based on our protocol, majority had a negative response. One child showed a positive response, contradicted by thorough microscopic inspection. Despite a positive response, the filum was untethered. IONM was not associated with any complication in this study. FTL untethering is an inherently low-risk microsurgery in experienced hands with rarely reported neurological morbidity. IONM may not be required for all FTL and may be used more judiciously.

EXTENDED Palliative (compassionate) medicines for COVID-19

Background: Neuromodulation techniques are an important part of the chronic refractory neuropathic pain treatment. Their effectiveness is insufficiently documented in patients with tethered cord syndrome. Case Description: We present the case of a 32-year-old woman with a history of myelomeningocele repair, followed by a detethering surgery complicated with cerebral fluid leakage. Her intractable pain in her left leg and low back was successfully treated with spinal cord stimulation. Pain intensity decreased from 8/10 to 1-2/10 on her visual analogue scale without regular analgesic intake and her quality of life improved significantly. Conclusions: A review of the literature documents only three case reports of similar efficacy of spinal cord stimulation in the treatment of pain in adult patients with tethered cord syndrome.

Spinal shortening osteotomy for adult tethered cord syndrome evaluated by intraoperative ultrasonography

BackgroundSpinal shortening osteotomy (SSO) reduces the tension indirectly in the spinal cord and minimizes perioperative complications. However, the most effective and safe length to which the spine can be shortened is still unknown. In our practice, we use somatosensory-evoked potentials, motor-evoked potentials, and intraoperative ultrasonography when performing SSO. This study aimed to introduce the clinical outcomes of our SSO technique for tethered cord syndrome (TCS) in adults. MethodsThis retrospective study included 7 adult patients (2 males and 5 females) with TCS treated between December 2010 and December 2018. The average age and average preoperative duration were 40 and 5 years, respectively. All patients received SSO with somatosensory-evoked potentials, motor-evoked potentials, and ultrasonography. After surgery, all patients were followed for an average of 4 years. ResultsThe mean operation time was 328 (284–414) min for SSO. The mean blood loss was 828 ml (501–1252 ml). Postoperative bony fusion was confirmed in all patients. Postoperative computed tomography (CT) demonstrated an average of 16 mm (11–20 mm) of spinal column shortening, compared with preoperative CT. Clinical improvements were obtained in all 7 cases, and there was no case of exacerbation. An indicator of shortening is that the ultrasonography gives pulsation and relaxation of the spinal cord. There were no abnormalities observed while monitoring the spinal cord. ConclusionsSpinal shortening should be done under somatosensory-evoked potentials, motor-evoked potentials, and intraoperative ultrasonography to obtain safe and sufficient shortening.

Outcome in 32 cases of tethered cord in adults-is intervention justified?

Adults rarely present with tethered cord syndrome, and this review examines whether it is justifiable to perform surgical intervention in this group. Between 2003 and 2017, we performed surgical intervention in 32 adults with tethered cord syndrome. The age range varied from 22 to 65years. 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 41years old. The mean follow-up was 3.2years. 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. 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.

Coexistence of Lumbar Intramedullary Lipoma and Epidermoid Tumor in a Child with Tethered Cord Syndrome: Case Report

Spinal epidermoid tumors and intramedullary lipomas are rare lesions of the spinal cord. In childhood, each of them may cause tethered cord syndrome (TCS). However, the coexistence of lumbar epidermoid tumors and intramedullary lipoma is much rarer. In this article, we present a 6-year-old female child who admitted with paraparesis and diagnosed lumbar epidermoid tumor and intramedullary lipoma causing TCS. She was treated surgically. Clinical presentation and surgical features of this rare case are presented and discussed. It should be kept in mind that children with TCS may have two tumors of different natures together, and both may contribute to the clinical picture of the patient.