Surgery For Tethered Cord Syndrome Research Articles

Intraoperative Neurophysiological Monitoring in Tethered Cord Syndrome Surgery: Predictive Values and Clinical Outcome.

"Tethered cord syndrome" (TCS) refers to a congenital abnormality associated with neurological signs and symptoms. The aim of surgery is to prevent or arrest their progression. This study reports a retrospective case series of tethered cord syndrome surgeries, supported by intraoperative neurophysiological monitoring. The case series comprises 50 surgeries for tethered cord syndrome in which multimodal intraoperative neurophysiological monitoring was performed using motor evoked potentials (transcranial motor evoked potentials [TcMEPs]), tibial nerve somatosensory evoked potentials (TNSEPs), and pudendal-anal reflex (PAR). The intraoperative neurophysiological monitoring results are reported and correlated with clinical outcomes. Sensitivity, specificity, and negative predictive value were high for TcMEPs and TNSEPs, while PAR exhibited low sensitivity and positive predictive value but high specificity and negative predictive value. Fisher's exact test revealed a significant correlation between changes in TcMEPs, TNSEPs, and clinical outcome ( P < 0.000 and P = 0.049 respectively), but no correlation was detected between PAR and urinary/anal function ( P = 0.497). While TcMEPs and TNSEPs were found to be reliable intraoperative neurophysiological monitoring parameters during tethered cord syndrome surgery, PAR had low sensitivity and positive predictive value probably because the reflex is not directly related to bladder function and because its multisynaptic pathway may be sensitive to anesthetics. New onset muscle weakness and sensory deficits were related to postoperative changes in TcMEPs and TNSEPs, whereas changes in PAR did not predict bladder/urinary impairment. Urinary deficits may be predicted and prevented with other neurophysiological techniques, such as the bladder-anal reflex.

Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome.

Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS). We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n= 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n= 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity. The diseases associated with leak formation included lipomyelomeningocele (n= 16), myelocystocele (n= 4), and myelomeningocele (n= 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n= 15), primary resuturing with local rotation flap of muscle (n= 3), external ventricular drain placement (n= 1), ventriculoperitoneal shunt (n= 3), external ventricular drainage (n= 1), and a combination of techniques (rotation flap with external drain; n= 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications. In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.

A review of the disagreements in the prevalence and treatment of the tethered cord syndromes with chiari-1 malformations

Background:The tethered cord syndrome (TCS) accompanying Chiari-1 (CM-1) malformations and the occult tethered cord syndrome (OTCS) syndrome accompanying the low lying cerebellar tonsil (LLCT) syndrome may be treated with sectioning of the filum terminale (SFT).Methods:Utilizing PubMed, we reviewed the neurosurgical literature to determine how frequently spinal neurosurgeons diagnosed the TCS (e.g., conus terminating below the normal L1-L2 disc level) on lumbar magnetic resonance (MR) studies in patients with CM-1 malformations [e.g. tonsils >5–12 mm below the foramen magnum (FM) warranting SFT]. In addition, we assessed how frequently spinal neurosurgeons encountered the OTCS (e.g., conus normally located at L1-L2 on MR) accompanying the LLCT (e.g., tonsils herniated <5 mm below the FM) also requiring SFT.Results:According to the neurosurgical literature, the incidence of TCS accompanying CM-1 requiring SFT ranged from 2.2% to < 6%, and up to 14%. Few studies additionally highly correlated the OCTS accompanying the LLCT syndrome warranting SFT.Conclusions:Given the differences in the literature, more studies are needed to assess the risks (complications) vs. benefits (improved neurological outcomes) of SFT surgery for TCS with CM-1 and SFT for OCTS with LLCT.

Surgery for tethered cord syndrome: when and how?

Tethered cord syndrome (TCS) is a clinical condition presented with neurological and/or urological signs and findings. Increased hypoxic stress in the spinal cord secondary to traction or stretching is the pathophysiological mechanism of TCS. It is usually observed in childhood but adult cases were also reported. Its diagnosis and treatment are always challenging. Magnetic resonance imaging, electrophysiological and urodynamic studies are the main diagnostic tools for TCS. This syndrome may be primary or secondary to previous surgeries such as myelomeningocele. Asymptomatic patients with low conus medullaris and thick filum terminale are always questionable for surgical treatment. On the other hand, symptomatic patients with normal radiological imaging are critical for surgical decision. Surgical treatment involves correction of the spinal pathologies and release of the spinal cord by cutting the filum terminale. Time of surgery and technical nuances are still in debate among neurosurgeons. Neurological and urological outcomes of the patients usually depend on these factors. Timing of surgery and surgical technique need to be clarified based on the recent clinical studies. This review will focus on the time and technique of TCS surgery. Firstly, a brief description of is e provided, then an extensive view on the surgical treatment of TCS will be performed.

24. IOM in tethered spine surgery

Tethered cord syndrome (TCS) is a disorder in which the distal spinal cord is tethered caudally to an immovable boney structure. This results in dysfunction of the lower spinal cord and cauda equina, manifest as lower extremity weakness, sensory loss, bowel and bladder dysfunction and occasionally musculoskeletal deformities. Surgery for TCS involves releasing the tethering structure and correcting the musculoskeletal abnormalities. Because the neural elements of the cauda equina are in close proximity, there is potential for damage to these structures during surgery. Neurophysiologic intraoperative monitoring (NIOM) can help prevent injury to these structures. NIOM for TCS surgery can include monitoring free running and stimulated electromyography (EMG), anal sphincter EMG, tibial nerve somatosensory evoked potentials (SEP), motor evoked potentials, bulbocavernosus reflex and pudendal nerve SEP. These monitoring modalities will be discussed.

Urodynamic outcomes of detethering in children: experience with 46 pediatric patients.

Tethered cord syndrome (TCS) manifests with neurological and urological complaints. Surgical detethering is the main treatment for TCS. Children with urological symptoms are required objective pre- and postoperative evaluations in order to predict urological outcome. The aims of this study are to investigate the effects of detethering procedure on the urodynamic tests and to determine the relationship between the changes of urodynamic tests and the patients' age and gender. The data of urodynamic tests in 46 pediatric patients, who underwent surgery for TCS, were retrospectively evaluated. Bladder capacity, post-voiding residual urine volume, maximum intravesical pressure, and bladder compliance of each patient were measured in preoperative period and at the third month after surgery. These parameters were statistically compared, and the correlations of these parameters with age, gender, and etiology of the TCS were also investigated. Bladder capacity and post-voiding residual urine volume were decreased and maximum intravesical pressure and bladder compliance were increased after surgery for TCS. The decrease in bladder capacity was significant in patients older than 10years (p<0.05). The increase in maximum intravesical pressure was also positively correlated with age (p<0.05). But the increase in bladder compliance was negatively correlated with age (p<0.05). Bladder capacity, post-voiding residual urine volume, and bladder compliance are mainly affected by surgery in patients with TCS. From the urological viewpoint, children older than 10years are most likely to benefit from surgery for TCS.

Comparison of Electrophysiological Outcomes of Tethered Cord Syndrome and Spinal Intradural Tumors: A Retrospective Clinical Study.

Electrophysiological evaluation of the outcomes of spinal procedures is important for neurosurgeons. Somatosensorial evoked potentials (SSEPs) are used for electrophysiological evaluation of tethered cord syndrome (TCS) and spinal intradural tumors (SIT). The aim of this study was to document the electrophysiological outcomes of surgery for TCS and SIT and to compare the results based on the preoperative diagnosis. The data of 30 patients, who were operated for TCS and SIT between 2011 and 2013, were reviewed retrospectively. Surgical release of the spinal cord was performed for TCS and tumor removal was performed for SIT. Median and tibial nerve SSEPs at the left and right sides were measured at preoperative, early and late postoperative periods and compared statistically based on the diagnosis and the time of electrophysiological assessment. The diagnosis was TCS in 12 (40%) patients and SIT in 18 (60%) patients. There was a significant difference between preoperative, and early and late postoperative SSEPs values. Tibial nerve latencies were prolonged in the early postoperative, but shortened in the late postoperative period. In contrast, median nerve latencies were shortened in the early postoperative, but prolonged in the late postoperative period. There was no significant difference between the TCS and SIT groups based on the surgical intervention. Tibial nerve latency may be prolonged in the early postoperative period of TCS and SIT patients. However, electrophysiological changes were not predictive for these patients. Further studies with more patients are needed for other spinal lesions.

Pathological evaluation of the filum terminale tissue after surgical excision.

Tethered cord syndrome (TCS) is an important disease and can produce progressive neurological symptoms. Studies about the filum terminale (FT) have drawn attention to the importance of histopathological investigation of this structure. The most interesting of these subtypes is the FT that incorporates peripheral nerve fibers (PNF). Our study aimed to analyze the frequency of PNF in the FT of 40 cases diagnosed with TCS. We performed a retrospective histopathological investigation of FT excised during surgery of patients with TCS who underwent de-tethering. Neurologic and other types of postoperative complications were also revised. Analysis of the samples showed six dominant histopathological subtypes in the FT: fibroadipose tissues including peripheral nerve bundles (n = 14, 37%), fibroadipose tissue (n = 10, 25%), fibrous or adipose tissue (n = 7, 17%), glial tissues including peripheral nerve sections (n = 4, 10%), and ependymal and glial tissues (n = 4, 10%). None of the patients presented with neurologic postoperative complications. Embryologic studies revealed that it is common to encounter different histological subtypes of FT pathology. However, the presence of peripheral nerve cells in the FT is important for neurosurgical practice due to the risk of sectioning a functional structure during surgery. In our analysis, we demonstrated the high frequency of PNF in FT pathology. However, since none of the patients showed any symptoms of neurologic deterioration, we considered that these fibers were probably not functional. Our findings emphasize the importance of neuromonitoring in TCS surgery. Although we consider that most of the fibers are probably not functional, neuromonitoring after surgery may prevent serious complications.

Sudden Appearance of New Upper Extremity Motor Function While Performing Neurophysiologic Intraoperative Monitoring During Tethered Cord Release

: Tethered cord syndrome occurs when the distal spinal cord or filum adheres to adjacent structures resulting in progressive sensorimotor deficits in the lower extremities, fecal and/or urinary incontinence, and musculoskeletal deformities. Tethering of the distal cord may be idiopathic, may be associated with an intraspinal abnormality such as a lipoma, but most commonly the distal spinal cord remnant is adherent to the area of the original dysraphism repair in patients with myelodysplasia. Surgery to untether the cord is indicated in patients with worsening pain symptoms, progressive limb deformity or spasticity, or before any acute correction of an associated spinal deformity. Neurophysiologic intraoperative monitoring is used to minimize the risk of inadvertent nerve root or spinal cord injury during the untethering procedure and to assess any changes in cord function at the time of an associated spinal deformity correction. We present a patient with a lumbar level myelodysplasia, Chiari II malformation, severe scoliosis, and tethered cord that underwent concurrent scoliosis correction and tethered cord syndrome surgery, who demonstrated immediate intraoperative improvement in neurophysiologic responses in a previously flaccid upper extremity after untethering. These monitoring changes correlated with clinical improvements noted by physicians and family postoperatively. Level IV.

Prognostic Value of Neurophysiologic Intraoperative Monitoring in Tethered Cord Syndrome Surgery

Neurophysiologic intraoperative monitoring is used in surgery for tethered cord syndrome. Our objective was to determine if neurophysiologic intraoperative monitoring is helpful in identifying which patients will have worsening symptoms after surgery. The spinal cord was stimulated before and after untethering until a motor response was obtained. The pre- and postoperative neurologic examination findings were noted. The motor response thresholds before and after untethering were compared using Student t tests. Forty patients were identified; 37 had higher motor response thresholds before untethering, whereas in three thresholds were higher after untethering. Of the 37 patients, two had worsening of motor function. All three patients with higher thresholds after untethering had worsening of motor function (P < 0.0001). An increase in the motor response threshold after surgical release of tethered cord syndrome indicates possible worsening of clinical symptoms. Spinal cord stimulation during tethered cord syndrome surgery may help predict neurologic outcome.

Neurophysiologic Intraoperative Monitoring During Surgery for Tethered Cord Syndrome

Tethered cord syndrome (TCS) occurs when the distal spinal cord is adherent to inelastic tissue. This results in sensorimotor deficits in the lower extremities, bowel and bladder dysfunction, and musculoskeletal deformities. Tethered cord syndrome is often found in childhood, but may be first noticed in adults as well. The symptoms are usually progressive unless halted by surgical correction of the spinal cord tethering. Surgery for TCS can be complicated by inadvertent injury to nerves that are either embedded in the tether or in close proximity to it. In an attempt to reduce this iatrogenic injury, neurophysiologic intraoperative monitoring is used to identify neural structures in the surgical field and reduce the risk of injury. Many neurophysiologic intraoperative monitoring paradigms have been used in TCS surgery, including free running and stimulated electromyography of the muscles of the lower extremities, external anal and external urethral sphincter electromyography, tibial, clitoral, and dorsal penile somatosensory evoked potentials, and bulbocavernosus reflex testing. It is widely believed that neurophysiologic intraoperative monitoring helps reduce morbidity of TCS surgery, but data supporting this are limited. This article will review the various neurophysiologic intraoperative monitoring paradigms that can be used in TCS surgery and discuss the data supporting the use of these paradigms.

Tethered cord syndrome: nationwide inpatient complications and outcomes

Object Previous investigations of health outcome after spinal surgery for tethered cord syndrome (TCS) have been single-institution studies. The aim of this study was to report inpatient complications and outcomes on a nationwide level. Methods The Nationwide Inpatient Sample (NIS) was used to identify patients who underwent spinal surgery for TCS in the US between 1993 and 2002. Patients who had a primary diagnosis of TCS (ICD-9 742.59) and also underwent spinal laminectomies were included in this study. Multivariate analysis was performed to analyze the effects of patient and hospital characteristics on variables such as mortality rate, nonfatal complications, LOS, and adverse outcomes in general (defined as death or discharge to an institution rather than home). Results The NIS sample included data on 9733 patients with TCS who underwent surgery. The means for mortality rate, complication rate, and LOS, respectively, were 0.0005%, 9.48%, and 5.6 days. Postoperative hemorrhages or hematomas (mean rate 2.3%) were the most common complications reported. Age and complications were the only significant predictors of adverse outcome on multivariate analysis. Patients older than 65 years had a threefold increase in risk of adverse outcome compared with patients 18 to 44 years of age. On average, one postoperative complication led to a 3-day increase in mean LOS and added more than $9000 to hospital charges. Conclusions This study provides a national perspective on inpatient complications and outcomes after spinal surgery for TCS in the United States. The authors have demonstrated the impact of age, complications, and medical comorbidities on the outcome of surgery for patients with this common disorder.