Pathophysiology of tethered cord syndrome: correlation with symptomatology

Yamada, Shokei; Won, Daniel J.; Yamada, Shoko M.

doi:10.3171/foc.2004.16.2.7

Cited by 112 publications

(66 citation statements)

References 26 publications

(43 reference statements)

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“…The changes in mitochondrial redox ratios and interneuron potential changes that occurred in animal models of spinal cord traction were similar to those observed during hypoxemia and ischemia [32]. Also glucose consumption of the stretched spinal cord was found to have an essential role in the pathophysiology of the TCS.…”

Section: Discussionsupporting

confidence: 65%

Lateral tethering intraspinal lipoma with scoliosis

et al. 2010

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The authors present an unusual case of an intradural lipoma at the thoracolumbar level causing lateral tethering of the spine, with complicated scoliosis. A 6-year-old girl was admitted with progressive change in posture detected by her parents. Thoracolumbar scoliosis was detected by physical examination and X-ray studies. Spinal magnetic resonance imaging revealed an intradural lipoma and right lateral tethering of the spine at the upper lumbar level. After surgical release of lateral tethering and resection of the lipoma, fusion was performed by the orthopedic surgery team. Radiological and intraoperative findings of this extremely rare case are discussed.

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Section: Discussionsupporting

confidence: 65%

Lateral tethering intraspinal lipoma with scoliosis

et al. 2010

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“…These insights have begun to elucidate the pathophysiology behind this disorder. 16,[21][22][23] However, what is still not clear is whether the adult tethered spinal cord and the pediatric tethered spinal cord share the same disease process and pathophysiology, or if they represent 2 different pathological processes, which could explain the different ages at presentation and different presenting symptoms.…”

mentioning

confidence: 99%

Pathophysiology of adult tethered cord syndrome: review of the literature

Stetler

Park²,

Sullivan³

2010

FOC

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Object Tethering of the spinal cord has been a recognized cause of neurological symptoms in pediatric patients and is increasingly being recognized as a cause of symptoms in adults as well. The pathophysiology surrounding spinal cord tethering has begun to be understood in the pediatric population but is still unclear in adult patients. Methods Using a PubMed database literature search, the authors reviewed the pathology and pathophysiology surrounding the tethered spinal cord, focusing particularly on the pathophysiology of adult tethered cord syndrome (TCS). Results Experimental data obtained in pediatric patients at surgery and in animal models indicate that spinal cord tethering causes a reduction in spinal cord blood flow and dysfunction of neuronal mitochondrial terminal oxidase. Retrospective analyses of patients undergoing surgery for adult TCS show that many adults developed symptoms following an event that could stretch the spinal cord, while others did not. Many patients also were found to have structural lesions in addition to a tethered spinal cord at diagnosis. Conclusions Both adult and pediatric TCSs are likely the result of a relative lack of blood flow to the spinal cord, causing dysfunction in mitochondrial oxidative phosphorylation. The likely reason the syndrome present later and differently in adults is that a secondary threshold of tension or a cumulative effect of repetitive, transient tension is placed on the cord before symptoms are recognized.

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“…24 In doing so, we hope to thwart further neuro logical deterioration, to reverse current neurological defi cits, to avoid iatrogenic injury, and to prevent retethering. Achieving these goals requires aggressive and maximal untethering, which is complicated in STCS by prior re pair of spinal dysraphism and disrupted anatomy of the caudal spine.…”

Section: Discussionmentioning

confidence: 99%

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Pouratian¹,

Elias²,

Phillips

et al. 2010

FOC

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Object Many patients develop neurological symptoms related to spinal cord tethering after perinatal repair of myelomeningocele. This is referred to as secondary tethered cord syndrome (STCS). The authors describe their methodology and evaluate the intraoperative utility and postoperative outcomes of electrophysiologically guided untethering for STCS. In addition, the authors describe the use of electrophysiological guidance to identify an “autonomous placode” in the untethering of the cord in STCS. Methods The authors retrospectively identified 46 untethering procedures in 38 patients who had undergone perinatal myelomeningocele repair and in whom the index surgery was for tethered cord release at the site of the repair. In all cases, both passive (electromyography) and active (detection of compound muscle action potentials) electrophysiological monitoring was used. The proximity to neural elements was determined based on the current used; eliciting compound muscle action potentials with a ≤ 10-mA stimulation was assumed to represent direct neural stimulation. Clinical records were reviewed to evaluate the utility of electrophysiological guidance and patient outcomes. Results The median age at the time of untethering was 9.5 years (range 0.5–54 years). The median follow-up time was 42 months (range 3–172 months). Progressive bowel and bladder dysfunction, diagnosed either clinically or by cystometrogram, and low-back pain were the most common presenting symptoms. Intraoperative findings indicated that the most common causes of tethering were dense scar (76%) and a tethered placode (39%). Electrophysiological monitoring identified functional neural tissue near tethered elements and provided intraoperative guidance in all cases. In 41% of cases (19 cases), the untethering plan was noted to have been significantly influenced by intraoperative neurophysiological findings. Moreover, an autonomous placode was identified in 6 patients who were nonambulatory preoperatively and had presented with increasing pain and spasticity. In electrophysiologically silent areas, more aggressive dissection and untethering were possible. Symptoms of low-back pain, lower-extremity paresthesia, and lower-extremity spasticity were most likely to improve after untethering surgery (91, 88, and 82%, respectively). Sectioning above the electrophysiologically defined autonomous placode resulted in significant improvement in back pain and lower-extremity spasticity in 5 of 6 patients. There was 1 case of immediate postoperative neurological deterioration (fecal incontinence). All patients remained clinically stable or improved on long-term follow-up, except for 6 (16% of patients) who required a total of 7 additional procedures for recurrent symptoms (median time to repeat surgery 36 months). Complications were noted in 8 cases, including infections and CSF leaks. Conclusions Surgical untethering of STCS halts progression and often improves preoperative symptoms. Electrophysiological monitoring, using both a threshold-based interpretation system and continuous electromyography monitoring, provides an efficient, effective, and reliable method for intraoperative guidance, thereby limiting iatrogenic injury and providing a means to identify and untether autonomous placodes. Electrophysiological monitoring also allows for more aggressive dissection and untethering in functionally silent regions, possibly decreasing retethering rates.

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Pathophysiology of tethered cord syndrome: correlation with symptomatology

Cited by 112 publications

References 26 publications

Lateral tethering intraspinal lipoma with scoliosis

Lateral tethering intraspinal lipoma with scoliosis

Pathophysiology of adult tethered cord syndrome: review of the literature

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

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