Symptomatic Tethered Cord Syndrome Research Articles

Recurrent tethered cord: outcome and follow-up of 20 de-thetering for symptomatic spina bifida: choort study.

The objective of this study was to evaluate the prevalence of tethered cord among patients in the postoperative period of open and occult spina bifida. To identify warning signs for its early diagnosis, as well as outcomes after the new surgical approach. Retrospective study of patients followed at the Pediatric Neurosurgery Department of the Federal University of São Paulo with spinal dysraphism. Signs and symptoms indicating reoperation were collected, and postoperative results were classified as improved, unchanged, or worsened. 222 medical records of patients diagnosed with spinal dysraphism were evaluated. Symptomatic Tethered Cord Syndrome (STCS) was identified in 30 patients (13.51%), with clinical manifestations related to orthopedic deformities (66.7%), neurological deficits (56.7%), urological dysfunction (50%), and intestinal dysfunction (40%). 20 cases underwent surgery for tethered cord release. The mean age at the time of surgery was 7.7 ± 4.9years, with 13 female patients (65%). In the postoperative evaluation, improvement in low back pain (90.9%), urological pattern, and urinary tract infection episodes (45.4%) were particularly noteworthy. 3 patients (33.3%) with constipation showed improvement, and one worsened (11.1%). Improvement in ambulation was seen in two cases (16.7%). Low back pain was the first symptom to improve after surgery, with an average time of 1.3months, followed by changes in the urological pattern at 15.6months. Improvement in constipation was observed in the first month in 2 cases (66.7%), positive changes in ambulation were observed around 7months after surgery, and only one case showed improvement in clubfoot correction. The prevalence of tethered cord recurrence after primary correction surgery for open or occult neural tube closure defects was similar to that found in the literature. The results were encouraging, with good postoperative evolution of patients, especially in the improvement of low back pain and urological symptoms.

A Study of Outcome of Detethering in Delayed Presentation of Tethered Cord Syndrome

Abstract Introduction Tethered cord syndrome (TCS) is a stretch-induced functional disorder associated with tethering of caudal spinal cord to dura mater with inelastic tissue, limiting its movement. It not only manifests in childhood but also noted in adults. Here, we studied the role of detethering on delayed presentation of TCS. Material and Methods All patients of symptomatic TCS from January 2011 to December 2019 were included. Preoperative evaluation was done through X-ray; ultrasonography kidney, ureter, urinary bladder; magnetic resonance imaging spine and brain; and urodynamic studies. Detethering was done and associated pathology was excised. Preoperative and postoperative comparison was done through Necker functional score using chi-squared system. Results Age range was 8 to 30 years with mean age of 13.8 years. Most common presentation was urological manifestations in ∼61.1% of cases followed by pain in 41.6%, sensory deficits in 38.8%, asymmetric weakness in 30.5%, orthopaedic and trophic ulcers in 22.2% each, and bowel abnormalities in 13.8% of cases. Mean duration of symptoms was 5.52 years. Improvement in urological manifestations was in 71.4% patients, pain in 80%, sensory dysfunctions in 71.4%, bowel dysfunctions in 80%, motor weakness in 90.9%, and trophic ulcer in 100% patients. On comparison, chi-squared value was 25.9993 and p-value was 0.000032, which was significant (<0.05). Conclusion Detethering in early ages is already proven with good results. In our study, detethering showed statistically significant improvement even in delayed presentation. So, authors recommend to surgically interfere by detethering, even if tethering is detected late with significant deficits.

Surgical outcome of pediatric patients with symptomatic tethered cord syndrome at a tertiary care hospital

Introduction: Patients with tethered cord syndrome become symptomatic during the period of their growth spurt. Apart from progressive foot and spinal deformities, patients also develop motor deficits and bladder and bowel dysfunction. Early diagnosis and adequate release of the tethered cord are indispensable to successful management.
 Objectives: To study the trends in the neurological outcome after surgical treatment of cord tethering in pediatric population.
 Methodology: Study was carried out from January 2018 to December 2019 at neurosurgery department, Fauji Foundation Hospital Rawalpindi. Thirty-five patients were included in the study who fulfilled the inclusion criteria.
 Results: The average age of the patients at the time of the intervention was 11 years. There were 21 females (60.0%) and 14 males (40.0%). The distribution of neurological status improvement tells improvement in back pain in 28 patients (80%), improvement in motor function in 14 patients (40%), and improvement in urinary incontinence in 7 patients (20%).
 Conclusion: This study concludes that back ache improves significantly after surgery while urinary incontinence is the least benefited symptom. Untethering along with the rehabilitation also helps majority of the patients with motor deficit. The ratio of symptomatic relief was best for backache and motor function and then improvement in the urinary control.

Tethered Cord Syndrome

Tethered cord syndrome (TCS) is a clinical condition of various origins, which comprises of progressive neurological, urological, and orthopaedic dysfunction, because of congenital fixation or tethering of the distal spinal cord by the terminal filum. It is believed that, if the filum elasticity is compromised by either fatty infiltration or abnormal thickening, the spine movement may cause stress upon the conus, resulting in TCS.Patients with symptomatic TCS can present with a wide variety of signs and symptoms in combination with cutaneous, orthopaedic, spinal, anorectal, and urological abnormalities. The common clinical presentations include the presence of cutaneous signs associated with open septal defects, neurogenic bladder with incontinence or urinary tract infection, leg or foot weakness, numbness and/or spasticity, differences in leg or foot length, deformities of the foot, spinal deformities, and back and leg pain.Neuroimaging is used to confirm when there is suspicion of TCS. Magnetic resonance imaging is the modality of choice in visualizing the level of the conus medullaris and for identifying a thickened and/or fatty filum.The fundamental goals of surgical intervention in TCS are to prevent future deficits in the asymptomatic patient and to improve or stabilize deficits in the symptomatic patient. These two goals are based on the fact that sectioning of the terminal filum can be done safely with minimal risk and a very low rate of morbidity. The reported complications of surgery are cerebrospinal fluid leakage (most common), wound infection, meningitis, bladder dysfunction, and neurological injury.

Tethered Cord Syndrome

Tethered cord syndrome (TCS) is a clinical condition of various origins, which comprises of progressive neurological, urological, and orthopaedic dysfunction, because of congenital fixation or tethering of the distal spinal cord by the terminal filum. It is believed that, if the filum elasticity is compromised by either fatty infiltration or abnormal thickening, the spine movement may cause stress upon the conus, resulting in TCS.Patients with symptomatic TCS can present with a wide variety of signs and symptoms in combination with cutaneous, orthopaedic, spinal, anorectal, and urological abnormalities. The common clinical presentations include the presence of cutaneous signs associated with open septal defects, neurogenic bladder with incontinence or urinary tract infection, leg or foot weakness, numbness and/or spasticity, differences in leg or foot length, deformities of the foot, spinal deformities, and back and leg pain.Neuroimaging is used to confirm when there is suspicion of TCS. Magnetic resonance imaging is the modality of choice in visualizing the level of the conus medullaris and for identifying a thickened and/or fatty filum.

Abstract: Myofascial Flap Closures Decrease Cerebrospinal Fluid Leaks in Tethered Cord Patients

INTRODUCTION: The benefits of spinal surgery for patients with symptomatic tethered cord syndrome are well-described, however complications such as cerebrospinal fluid leak, seroma, and infection frequently occur. Recent studies have shown many advantages of myofascial flap closure for various spinal procedures. This study investigated whether the collaboration between neurosurgery and plastic surgery results in better outcomes and lower complications for patients undergoing tethered cord release. METHODS: A retrospective review of patients presenting to Weill Cornell Medical Center from 2010 to 2014 for tethered cord surgery was performed. All patients who underwent tethered cord release by three neurosurgeons with or without involvement of a plastic surgeon were included in the study. Data including patient demographics, medical co-morbidities, surgical history, complications, and follow-up information were collected and analyzed from clinical charts. RESULTS: Sixty-six patients underwent tethered cord release at Weill Cornell Medical Center from 2010 to 2014. Fifty-one (77%) patients had tethered cord release without myofascial flap closure, while fifteen patients (23%) had tethered cord release with myofascial flap closure. In the non-flap group, there were 46 primary dural closures (92%) with 6 cases of cerebrospinal fluid leak (12.7%), 10 reoperations (19.6%), 5 infections (9.8%), and 3 seromas (6.4%). In the myofascial flap group, there were 11 primary dural closures (78%) with no cerebrospinal fluid leaks, no reoperations, 1 infection (6.7%), and 1 seroma (6.7%). CONCLUSION: Our results suggest that patients undergoing tethered cord release may benefit from myofascial flap spine closure. Bringing in well-vascularized tissue to obliterate potential space and create a water-tight seal around the dural repair can decrease rates of cerebrospinal fluid leak. This study supports the idea that neurosurgical patients should consider plastic surgical consultation when considering tethered cord surgery. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.

Surgical Outcome of Children and Adolescents with Tethered Cord Syndrome

Study DesignRetrospective cohort study.PurposeTo compare long-term results of surgery with the outcomes of symptomatic and asymptomatic tethered cord syndrome (TCS) in children and adolescents and to assess the surgery duration for those with TCS.Overview of LiteraturePediatric patients with TCS continue to pose significant diagnostic and management challenges.MethodsWe retrospectively analyzed the outcomes of 31 patients (16 males, 15 females) with TCS, including 21 with lumbosacral lipoma. All were surgically treated between 1989 and 2015. They were divided into symptomatic and asymptomatic TCS groups. The results of the treatment were summarized and analyzed using a non-parametric Mann–Whitney U test.ResultsNineteen patients had symptomatic TCS and 12 had asymptomatic TCS. Patients had a median age of 34 months (range, 0–201 months). The median follow-up period was 116 months (range, 7–223 months). Of the 19 symptomatic TCS patients, preoperative deficits improved after surgery in two (10.5%) and remained stable in 17 (89.5%) patients. One of the 12 asymptomatic TCS (8.3%) patients showed an exacerbated illness after surgery, and one in 11 patients remained stable (11.7%). There were significant differences in monthly age at surgery, preoperative bowel and bladder dysfunction, neurological function, presence/absence of clean intermittent catheterization introduction, and presence/absence of motor disorder at final follow-up (all p<0.05). In the univariate analysis, the presence/absence of preoperative bowel and bladder dysfunction, and symptoms were strongly associated with the risk of children and adolescents with TCS (p<0.05).ConclusionsEarly accurate diagnosis and adequate surgical release might lead to successful outcomes in children and adolescents with TCS. Surgical untethering is a safe and effective method for treatment of children with TCS.

Homogeneous spinal-shortening axial decompression procedure for tethered cord syndrome

Surgical detethering is a traditional treatment for symptomatic tethered cord syndrome. However, such complications as cerebrospinal fluid leakage and neurologic deterioration are common. Homogeneous spinal-shortening axial decompression (HSAD) is a modified procedure of monosegmental spinal-shortening osteotomy and it is a novel surgical alternative of reducing neural tension indirectly. The objective was to evaluate the surgical outcomes of HSAD for tethered cord syndrome. The surgical outcomes were examined for 15 consecutive patients with tethered cord syndrome undergoing HSAD from April 2010 to July 2014. Improvements of neurological symptoms including urinary dysfunction, lower-extremity motor and sensory disturbances and/or gait abnormalities, low-back and/or lower-extremity pain, bowel incontinence and sexual dysfunction were evaluated. Their average follow-up period was 21.5 months. The length of spinal column shortening was 17.2 ± 2.9 mm. Urinary dysfunction (n = 9) was the most common residual deficit. All 9 patients with urological symptoms reported improvements, although deficits persisted at the last follow-up. All patients with lower-extremity motor dysfunction improved and 4 (50.0%) noted complete resolution of preoperative lower-extremity sensory symptoms. All patients reported immediate low-back or lower-extremity pain relief after HSAD. One patient reported improved sexual functioning and regained complete erectile capabilities. Two patients (11%) experienced less satisfactory symptomatic or functional benefit from HSAD. However, the main objective of surgery was to prevent further worsening of neurological status. Complete bone union at osteotomy site was noted in all cases at the last follow-up. As a novel surgical option for tethered cord syndrome, HSAD may avoid such complications as cerebrospinal fluid leakage or neurologic deterioration commonly encountered during traditional detethering surgery. All patients gain satisfactory functional outcomes without complications compared to their preoperative symptoms.

Management of Tethered Cord Syndrome in Adults: Experience of 23 Cases.

Tethered cord syndrome (TCS) is rarely diagnosed in adults. It is a complex clinicopathological entity that remains poorly understood. In this study, clinical outcomes of 23 consecutive congenital TCSs diagnosed in adults have been evaluated to establish a standard approach to treat congenital TCS diagnosed in adults. Medical records were retrospectively reviewed in 73 cases of TCS who were underwent surgery in our hospital, between 2005 and 2014. Cases which diagnosed and treated surgically in adults (patient age > 18 years) were included in this study. Twenty-three adult cases of TCSs were treated surgically and 15 of them were female and 8 were male. The mean age was 30.3±10.7 years. The mean follow-up period was 75.6±40.5 months. The most common complaint was low back pain. The most common findings in the neurological examinations were muscular weakness and urinary incontinence. The most common co-malformations were diastematomyelia and vertebral fusion anomalies. Conus medullaris was mostly terminated at the L5 level. Detethering procedure was carried out in 87% of patients and bony septum resection without detethering was applied in 13%. Laminoplasty was performed only in 39.1%. 60.9% of patients were recovered good. 34.8% of patients were improved. The most common complication was cerebrospinal fluid leakage. Despite the good results obtained in our surgical interventions for symptomatic TCS in adults, tethered cord releasing is complex procedure and has serious complications. Therefore, it is suggested to plan surgery according to symptoms emphasized with full neurological examination, craniospinal imaging and urodynamic tests.

Multisegmental Spinal-Shortening Osteotomy for the Treatment of Tethered Cord Syndrome: A Retrospective Study of Six Consecutive Cases

Introduction Tethered cord syndrome often presents as low back pain in the early stage and progresses to sensory, motor, bowel, and bladder control dysfunctions. The pathogenesis of tethered cord syndrome is thought to be abnormal longitudinal traction on the caudal end of the spinal cord. Surgical detethering has been considered the gold standard for symptomatic tethered cord syndrome and consistently shown to be effective. However, complications such as cerebrospinal fluid leakage, infection, and neurologic deterioration including motor and bladder function are common. To minimize these complications, vertebral column subtraction osteotomy and pedicle subtraction osteotomy were reported as alternative procedures for the treatment of adult tethered cord syndrome. The concept of the procedures is to reduce neural tension indirectly. We present six consecutive cases with tethered cord syndrome that underwent a modified spinal-shortening osteotomy, which is multisegmental. Materials and Methods We retrospectively reviewed the surgical and radiological data of patients with tethered cord syndrome who underwent multisegmental spinal-shortening osteotomy (MSSO) by one doctor in one of the surgery groups at Changzheng Hospital from July 2009 to July 2013. The average follow-up period was 32 ± 7.5 months. Three patients were male and three were female and the average age at operation was 33 years (range, 16-57 years). MSSO were performed in patients, which required multilevel discectomy and facetectomy. The certain length gap created by the discectomy and facetectomy were then closed with serial compression through the domino connectors. Temporary rods were replaced with permanent rods once final spinal column alignment was achieved. The shortening of the spine was measured at the anterior and posterior borders and the midpoint of the vertebral end plate on the lateral fluoroscopy. Preoperative and postoperative VAS pain scores were evaluated. Results Six patients were followed up for 32 months in average and were included in the analysis. The length of spinal column shortening was 17 ± 1.7 mm. Urinary and sensory dysfunctions (two cases for each) were the most common residual deficits. Two (100%) patients with urological symptoms reported improvements, although deficits remained at the time of last follow-up. Six patients with lower-extremity motor dysfunction improved and six noted complete resolution of preoperative lower-extremity sensory symptoms. Five (100%) reported immediate low back or lower extremity pain relief following MSSO. VAS pain scores of all six patients were greatly improved after surgery. Complete bone union at the osteotomy site was noted in all cases at the time of last follow-up. Conclusion Most of the patients who have undergone MSSO in our study exhibited improvement of urological symptoms, complete recovery of motor functioning, and relief of debilitating back or lower extremity pain. Although many factors preclude a direct comparison of the symptomatic and functional outcomes following traditional surgical detethering compared with MSSO for TCS treatment, the outcomes are grossly similar regarding current literature. We believe that the principal benefits of MSSO over detethering operations will be in preserving the symptomatic and functional neurological improvements with lasting results and potentially obviating the need for future reoperations. However, longer follow-up results are needed from the MSSO series to support this belief. Disclosure of Interest None declared References Agarwalla PK, Dunn IF, Scott RM, Smith ER. Tethered cord syndrome. Neurosurg Clin N Am 2007;18(3):531–547 Alemdaroğlu KB, Atlihan D, Cimen O, Kilinç CY, Iltar S. Morphometric effects of acute shortening of the spine: the kinking and the sliding of the cord, response of the spinal nerves. Eur Spine J 2007;16(9):1451–1457 Hsieh PC, Stapleton CJ, Moldavskiy P, et al. 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(1):E6 Kanno H, Aizawa T, Ozawa H, Hoshikawa T, Itoi E, Kokubun S. Spine-shortening vertebral osteotomy in a patient with tethered cord syndrome and a vertebral fracture. Case report. J Neurosurg Spine 2008;9(1):62–66 Kawahara N, Tomita K, Kobayashi T, Abdel-Wanis ME, Murakami H, Akamaru T. Influence of acute shortening on the spinal cord: an experimental study. Spine 2005;30(6):613–620 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(1):21–27 Miyakoshi N, Abe E, Suzuki T, Kido T, Chiba M, Shimada Y. Spine-shortening vertebral osteotomy for tethered cord syndrome: report of three cases. Spine 2009;34(22):E823-E825 Traynelis VC. Spine shortening of tethered cord. J Neurosurg Spine 2011;15(1):19-20, author reply 20

The spectrum of musculoskeletal problems in lipomyelomeningocele

Patients with lipomyelomeningocele (LMMC) represent a unique population within the spectrum of spinal dysraphism. The natural history of LMMC remains poorly defined. The description and prevalence of the presenting orthopaedic clinical signs and symptoms for LMMC have been infrequent and often documented only in general terms. The goal of this study is to define the patterns and prevalence of presenting clinical musculoskeletal signs and symptoms in LMMC patients. This study was a retrospective review of charts of all patients identified as having LMMC in our spina bifida clinic. Patient charts with incomplete data or diagnoses other than LMMC were excluded from the analysis. Data collected included age at initial tethered cord release (TCR); repeat TCR; limb length discrepancy; foot deformities; asymmetry of motor and sensory deficits; presence of scoliosis; orthotic needs; assistive devices; functional status. We identified 32 patients with LMMC (21 female and 11 male patients). The majority of patients had their primary TCR by ≤1 year of age (59 %), with 22 and 19 % having primary TCR at ages 1-15 and >15years, respectively. Fifteen patients had at least one repeat TCR, with ten of these having more than one repeat TCR. A significant relationship was noted between low back/radicular pain and repeat TCR (p<0.001). Ten patients (31%) had a limb length discrepancy of >2.5cm, and 53 % of patients had asymmetric involvement. Nine patients (28 %) had scoliosis of whom only one required operative treatment. Fifteen patients had foot deformities. Thirteen patients (41 %) had two or more orthopaedic procedures in addition to other neurologic or urologic procedures. The presenting musculoskeletal clinical signs and symptoms in patients with LMMC are uniquely different in terms of both pattern and frequency compared to myelomeningocele and other forms of spinal dysraphism. We noted a high prevalence of asymmetrical involvement, a high operative burden, and a high rate of repeat symptomatic tethered cord syndrome requiring TCR. As previously noted by others, TCR in LMMC does not prevent long-term functional deterioration. These findings may be important to our colleagues providing counsel to their patients with LMMC and to their families.

Spine-Shortening Vertebral Osteotomy for Tethered Cord Syndrome

Retrospective case series. To review findings from 3 patients who underwent spine-shortening vertebral osteotomy for tethered cord syndrome with a minimum follow-up of 3 years. 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. 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. 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. Spine-shortening vertebral osteotomy can be a safe and alternative surgical technique for tethered cord syndrome.

Incidence of symptomatic retethering after surgical management of pediatric tethered cord syndrome with or without duraplasty

Cord retethering and other postoperative complications can occur after the surgical untethering of a first-time symptomatic tethered cord. It is unclear if using duraplasty vs. primary dural closure in the initial operation is associated with decreased incidence of either immediate postoperative complications or subsequent symptomatic retethering. It is also unclear if different etiologies are associated with different outcomes after each method of closure. We reviewed our pediatric experience in first-time surgical untethering of symptomatic tethered cord syndrome (TCS) to identify the incidence of postoperative complications and symptomatic retethering after duraplasty vs. primary closure. We retrospectively reviewed 110 consecutive pediatric (<18 years old) cases of first-time symptomatic spinal cord untethering at our institution over a 10-year period. Incidence of postoperative complications and symptomatic retethering were compared in cases with duraplasty vs. primary dural closure use. Mean age was 5.7 +/- 4.8 years old. "Complex" etiologies included lipomyelomeningocele or prior lipomyelomeningocele repair in 22 (20%) patients, prior myelomeningocele repair in 35 (32%), and concurrent lumbosacral lipoma in 18 (16%). "Noncomplex etiologies" included fatty filum in 26 (24%) and split cord malformation in five (4%). Seventy-five (68%) cases underwent primary dural closure vs. 35 (32%) with duraplasty. Twenty-nine (26%) patients experienced symptomatic retethering at a median [interquartile range (IQR)] of 30.5 [20.75-41.75] months postoperatively. There was no difference in incidence of postoperative cerebrospinal fluid leak, surgical site infection, or median [IQR] length of stay in patients receiving primary dural closure [4 (5%), 7 (9%), and 5 (4-6) days, respectively] vs. duraplasty [3 (9%), 3 (9%), and 6 [5-8] days, respectively], p > 0.05. Complex etiologies were more likely to retether than noncomplex etiologies after primary closure (33.6% vs. 6.6%, p = 0.05) but not after duraplasty (13.7% vs. 5.4%, p = 0.33). Duraplasty graft type (polytetrafluoroethylene vs. bovine pericardium) was not associated with pseudomeningocele or retethering. In our experience, the increased rate of symptomatic retethering observed with complex pediatric TCS (pTCS) etiologies after primary dural closures was not observed when duraplasty was instituted. Expansile duraplasty may be valuable specifically in the management of patient subgroups with complex pTCS etiologies.

Intradural inclusion cysts following in utero closure of myelomeningocele: clinical implications and follow-up findings

The goal in this study was to evaluate the incidence and clinical implications of the development of cutaneously derived intradural inclusion cysts (ICs) following fetal myelomeningocele (fMMC) closure. Retrospective databases and responses to a parental questionnaire were reviewed to determine the incidence, clinical presentation, and outcomes of fMMCs in children in whom ICs developed at follow-up. Prior to the National Institutes of Health (NIH)-sponsored Management of Myelomeningocele Study (MOMS), 54 patients underwent fMMC closure at the authors' institution. Sixteen (30%) presented with symptomatic tethered cord syndrome (TCS) at a median age of 27 months (range 4-93 months). Ten (63%) of the 16 (19% of the total) developed TCS in association with an intradural IC. In 9 (90%) of 10 patients, the IC was seen on preoperative MR imaging, and in 1 it was found during surgery. Four additional children (7% of the total) with evidence of an IC on surveillance MR imaging are currently asymptomatic at 94, 84, 60, and 60 months of age, respectively. All but 1 (an L-3 level lesion) IC developed in infants with L-4 and L-5 defects. After cyst removal, 6 children are asymptomatic at a median follow-up of 36 months (range 12-63 months). Following IC removal, 4 children lost normal bladder function and now require clean intermittent catheterization, and 1 lost normal leg function and now requires a walking aid for ambulation. Histologically, 8 lesions were dermoid, 1 was an epidermoid, and 1 was a mixed dermoid-epidermoid IC. Three patients developed another IC and required its removal at 24, 39, and 51 months, respectively. One required another tethered cord release within 57 months after IC removal. Cutaneously derived intradural ICs can develop following fMMC surgery. Deterioration of bladder function, risk of recurrence, and loss of lower-extremity function appear to be the most important long-term complications of IC in children with fMMCs. The ongoing NIH-sponsored MOMS may help determine whether children with fMMC are at increased risk of IC development compared with children treated with postnatal MMC closure. Parents seeking fMMC closure should be informed about the possibility of IC formation and the potential clinical consequences.

Tethered cord syndrome in myelodysplasia: correlation between level of lesion and height at time of presentation.

The purpose of this study was to determine whether the onset of tethered cord syndrome is related to the level of the myelomeningocele (MMC) (sacral, low lumbar, high lumbar or thoracic) and the height and age of the patient at time of presentation. Of 163 patients followed, 18 underwent corrective surgery for symptomatic tethered cord syndrome. The level of lesion at time of presentation correlated highly with height and age. The mean height and age for each level at the time of surgery were: sacral 134.5cm, 9.3 years; low lumbar: 124cm, 9.9 years; high lumbar: 108cm, 4.9 years; thoracic: 92.4cm, 4.7 years. The author concludes that the sensorimotor level of patients with MMC is a useful clue in predicting the onset of symptoms related to tethered cord syndrome.