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

Samuels, Roger; McGirt, Matthew J.; Attenello, Frank J.; Ambrossi, Giannina L. Garcés; Singh, Neil; Solakoğlu, Can; Weingart, Jon; Carson, Benjamin S.; Jallo, George I.

doi:10.1007/s00381-009-0895-6

Cited by 64 publications

(32 citation statements)

References 17 publications

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“…[28][29][30]51 However, no cord tethering became symptomatic in a patient with a duraplasty. Goto et al 22 likewise limited postsurgical tethering by combining pial suturing with a duraplasty.…”

Section: 51mentioning

confidence: 99%

Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Klekamp

2013

SPI

109

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Object Surgery of intramedullary tumors is established as the treatment of choice for these challenging lesions. This study presents a detailed analysis of risk factors for surgical morbidity and data on long-term results for intramedullary tumors. Methods Among 1317 patients with tumors of the spinal canal treated between 1980 and 2012, 278 patients with intramedullary tumors are presented. A total of 225 of these patients underwent 246 operations for treatment of 250 tumors. The mean patient age was 41 ± 17 years (range 3 weeks to 83 years). Patients underwent follow-up through outpatient visits and questionnaires with a mean follow-up of 41 ± 53 months. Tumors were subdivided into 3 groups: displacing tumors (Type A, n = 162), infiltrating tumors (Type B, n = 80), and nonproliferating tumors (Type C, n = 8). A gross-total resection (GTR) was attempted for every tumor except for Type C lipomas. Participating surgeons were divided into 3 groups according to the number of operations they performed. Short-term results were determined for individual symptoms and the modified McCormick Scale, whereas tumor recurrence rates were calculated with Kaplan-Meier statistics. Results Overall, 83.3% of Type A tumors underwent GTR compared with 22.5% of Type B and none in Type C. Gross-total resection rates increased throughout the study period and correlated significantly with surgical experience. A worsened neurological state after surgery was seen in 61% of patients. This deterioration was transient in 41.5% and was a common observation after GTR. Permanent morbidity (19.5%) was lowest after GTR and correlated significantly with surgical experience and the preoperative neurological state. Further analysis showed that patients with tumors of thoracic levels, tumor hemorrhages, and malignant and recurrent tumors were at a higher risk for permanent morbidity. In the long term, tumor recurrence rates for ependymomas and benign astrocytomas correlated significantly with the amount of resection. Long-term morbidity affected 3.7% with a postoperative myelopathy related to cord tethering at the level of surgery and 21.9% in form of neuropathic pain syndromes. The rate of postsurgical cord tethering could be lowered significantly by using pia sutures after tumor resection. Neuropathic pain syndromes were more common after surgery for tumors with associated syringomyelia or those located in the cervical cord. Conclusions Intramedullary tumors should be surgically treated as soon as neurological symptoms appear. Gross-total resection is possible for the majority of benign pathologies. Cervical tumors are associated with higher GTR and lower permanent morbidity rates compared with thoracic tumors. Surgery on intramedullary tumors should be performed by neurosurgeons who deal with these lesions on a regular basis as considerable experience is required to achieve high GTR rates and to limit rates of permanent morbidity.

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Section: 51mentioning

confidence: 99%

Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Klekamp

2013

SPI

109

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“…A study comparing complex (myelomeningocele, lipomyelomeningocele) to noncomplex (fatty filum, split cord malformation) pathologies demonstrated a higher incidence of retether in complex pathologies with primary dural closure, but no statistical difference in retether with duroplasty. 59 A generous duraplasty, therefore, may in fact be protective against retethering by creation of a larger CSF space around the neural placode. 59 It should be noted that some late complications have been noted with Silastic duraplasty including neomembrane formation, which may predispose the patient to hemorrhage near the operative bed, and low virulence infections.…”

Section: Surgical Interventionmentioning

confidence: 99%

“…59 A generous duraplasty, therefore, may in fact be protective against retethering by creation of a larger CSF space around the neural placode. 59 It should be noted that some late complications have been noted with Silastic duraplasty including neomembrane formation, which may predispose the patient to hemorrhage near the operative bed, and low virulence infections. 16 Timing of surgical intervention has remained a rather controversial topic, with some advocating for intervention prior to presentation of neurological dysfunction, and some advocating for waiting to intervene until evidence of dysfunction exists.…”

Section: Surgical Interventionmentioning

confidence: 99%

Lipomyelomeningocele: pathology, treatment, and outcomes

Sarris

Tomei²,

Carmel³

et al. 2012

FOC

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Lipomyelomeningocele represents a rare but complex neurological disorder that may present with neurological deterioration secondary to an inherent tethered spinal cord. Radiological testing is beneficial in determining the morphology of the malformation. Specialized testing such as urodynamic studies and neurophysiological testing may be beneficial in assessing for neurological dysfunction secondary to the lipomyelomeningocele. Early surgical intervention may be beneficial in preventing further neurological decline.

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“…Expansile duraplasty has also been advocated to create more subarachnoid space, although it does introduce 2 new sites of potential adhesion at the suture line. 14 Samuels et al 9 treated 110 cases of symptomatic TCS, whose cause in 32% of the series was noncomplex, and 74% of the latter had fatty filum. The median length of follow-up was 42.5 months.…”

Section: Discussionmentioning

confidence: 99%

Fecal incontinence as a predominant symptom in a case of multiply recurrent tethered cord: diagnosis and operative strategies

Behaine

Latif

Greenfield

2015

PED

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T eThered cord syndrome (TCS) may be associated with myelomeningocele, lipomyelomeningocele, and lumbosacral lipoma or fibrolipomatous filum terminale or may be secondary to arachnoiditis or postsurgical scarring following an initial operative approach. Rates of retethering after sectioning a fatty filum terminale are low. 15,16 Retethering may produce neurological symptoms through nerve root traction and ischemia or tension distributed through the spinal cord. 3,4,12 We present a case of simple tethered cord due to a fatty filum terminale with 3 distinct episodes of recurrence, each presenting with fecal incontinence and resolving with operative intervention. At the last procedure, a discrete sacral nerve root was recognized and individual nerve roots were separated from the filum before its eventual complete resection. Symptoms had not returned at the 9-month follow-up. This case represents a unique clinical course and interesting pathophysiology that, to the best of our knowledge, has not been reported. case report History and ExaminationA healthy 4-year-old boy initially presented with severe constipation and abdominal pain concomitant with low-back and leg pain for which he was being managed with bowel regimens without improvement. Magnetic resonance imaging of the spine demonstrated a fatty filum terminale and tethered cord. The patient underwent tethered cord release at another institution, and his symptoms partially improved for 6 months before a recurrence of his initial symptoms. First RecurrenceThe patient's physical therapist noted new mild weakness of the left leg. Magnetic resonance imaging confirmed release of the filum terminale with the lipoma clearly disconnected, and the surgeon declined to reexplore. The child presented to our office at this time for a second opinion. We offered to perform an exploration at the original surgical abbreviatioN TCS = tethered cord syndrome. Recurrent manifestations of tethered spinal cord after an initial operative intervention for a simple fatty filum terminale is fairly uncommon. The authors present the case of an unusual clinical course in which there were 3 distinct episodes of recurrence, each time presenting predominantly as fecal incontinence and resolving with operative intervention. Typical signs of tethering were absent on radiological evaluation, and operative intervention was based on clinical grounds. Intraoperatively, sacral nerve roots to the anal sphincter were found tethered to the filar stump with electrophysiological evidence of regained activity on disentanglement. To the best of the authors' knowledge, a similar clinical course or operative findings have not been reported.

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

Cited by 64 publications

References 17 publications

Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Treatment of intramedullary tumors: analysis of surgical morbidity and long-term results

Lipomyelomeningocele: pathology, treatment, and outcomes

Fecal incontinence as a predominant symptom in a case of multiply recurrent tethered cord: diagnosis and operative strategies

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